scholarly journals Graft Failure in Adolescent Patients Undergoing Adult-Type ACL Reconstruction with Bone Patellar Tendon Bone or Hamstring Autograft

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0010
Author(s):  
Ashish Mittal ◽  
Sachin Allahabadi ◽  
Monica Coughlan ◽  
Nirav Pandya
Keyword(s):  
High Risk ◽  
Acl Reconstruction ◽  
Revision Surgery ◽  
Athletic Participation ◽  
Hamstring Autograft ◽  
Graft Size ◽  
Adult Type ◽  
Graft Rupture ◽  
Adolescent Patients ◽  
Bone Patellar Tendon

Introduction: Anterior cruciate ligament (ACL) injuries represent a quarter of high school knee injuries. Adult-type ACL reconstruction (ACL-R) is the treatment of choice for skeletally mature adolescent patients with a complete ACL tear. Graft choice is individualized to the patient, taking into account the patient’s anatomy, activity level, and athletic participation. This subset of patients is at perhaps the highest risk of failure due to demands on the reconstruction after surgery. Hypothesis/Purpose: The purpose of this study was to evaluate outcomes including graft rupture between bone-patellar tendon-bone (BTB) versus hamstring autograft in adolescent patients undergoing adult-type ACL reconstruction. Methods: A retrospective review of patients under the age of 21 undergoing primary adult-type ACL-R by a single surgeon using BTB or hamstring autograft between 2011 and 2019 was performed. Patient demographics, athletic participation, concomitant injuries, graft utilized, graft size, femoral and tibial fixation devices, compliance with rehabilitation protocol, complications, and rates of revision surgery were evaluated. Factors associated with graft failure were compared using Fisher’s exact test with statistical significance < 0.05. Results: 269 patients with an average age of 16.5 years (range 12.4-20.6) and an average follow-up of 2.1 years (range 0.4-6.6 years) were included. 52.5% of the patients were female. The overall graft rupture rate was 4.8%. There was no difference in average age, sex, compliance, and participation in high risk sports between graft type groups. Graft size was larger in patients with BTB autograft than patients with hamstring autograft (9.0 vs. 8.3; p<.001). There was no difference in the overall rate of re-operation between BTB and hamstring autografts (8.6% vs. 10.6%; p=0.81). There was no significant difference in rate of graft rupture with BTB and hamstring autograft (2.9% vs. 5.5%; p=0.26). Average time to revision surgery in those with ruptures was 1.7 years (range 0.7-4.7 years). 46% of patients had revision ACL-R with a different surgeon. There was no difference in age or participation in high risk sports between patients with and without graft tear. There was a higher percentage of documented compliance issues in patients with graft tear (46%) than without graft tear (29%), though not statistically significant (p=0.17). Conclusion: Rates of graft tear after ACL-R did not differ with BTB versus hamstring autograft. Rates of compliance and participation in high risk sports did not significantly differ in patients with and without graft tear. Many patients had a change in surgical provider for revision surgery.

scholarly journals GRAFT CHOICE FOR ADOLESCENT ATHLETES RETURNING TO HIGH-RISK SPORTS: A MATCHED COHORT ANALYSIS OF PATELLAR TENDON AND HAMSTRING AUTOGRAFTS

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0007
Author(s):  
Crystal Perkins ◽  
Michael Busch ◽  
Melissa Christino ◽  
Belinda Schaafsma ◽  
S. Clifton Willimon
Keyword(s):  
Anterior Cruciate Ligament ◽  
High Risk ◽  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Graft Rupture ◽  
Graft Choice ◽  
Anterior Cruciate

Background: Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level1-3. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport. Methods: A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 6-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture. Results: One hundred fifty-two patients with an average age of 16 years (range 13 – 18 years) underwent ACL reconstruction during the study period. There were 71 BTB reconstructions and 81 HS reconstructions. There were 64 females and 88 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (20%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (41%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (61% v 72%, p = 0.15), meniscus repair (21% v 32%, p = 0.13), or partial meniscectomy (32% v 33%, p = 0.90). Mean duration of follow-up was 28 months (range 7-57 months). There was no difference in follow-up between cohorts (BTB 28 months and HS 29 months, p = 0.19). There were a total of 16 graft ruptures (10.5%). There was no difference in the rate of graft rupture between cohorts (BTB 8.5% vs HS 12.3%, p = 0.60). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. Conclusions: ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84(9):1503-1513. Ho B, Edmonds EW, Chambers HG et al. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop 2016. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 2017;475(10):2459-2468.

scholarly journals Hamstring Autograft in ACL Reconstruction: A 13-Year Predictive Analysis of Anthropometric Factors and Surgeon Trends Relating to Graft Size

2018 ◽  
Vol 6 (6) ◽  
pp. 232596711877978 ◽  
Author(s):  
Prem N. Ramkumar ◽  
Michael D. Hadley ◽  
Morgan H. Jones ◽  
Lutul D. Farrow
Keyword(s):  
Acl Reconstruction ◽  
Graft Failure ◽  
Cruciate Ligament ◽  
Small Diameter ◽  
Large Cohort ◽  
Predictive Equation ◽  
Hamstring Autograft ◽  
Graft Size ◽  
Patient Demographics ◽  
The Mean

Background: Small-diameter autograft hamstring grafts have been linked to graft failure after anterior cruciate ligament (ACL) reconstruction. The frequency of hamstring autografts that actually meet ideal size criteria remains unknown. Purpose: To examine a large cohort of patients to (1) evaluate sizing variability among a large cohort of surgeons and (2) identify patient factors most predictive of hamstring autograft size. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1681 ACL reconstructions with hamstring autograft were analyzed as completed by 11 surgeons over a 13-year period. Patient demographics (age, height, weight, body mass index, sex) and intraoperative details (including graft diameter and strands) were extracted. Univariate and multivariate regression analyses were performed to correlate patient demographics with graft size and to develop a predictive model for hamstring graft size. Results: The mean height and weight of patients included in this study were 172.7 cm and 80.1 kg, respectively; 59% of patients were male. The mean diameters of hamstring autografts were 8.4 mm and 8.2 mm for the tibial and femoral ends of the graft, respectively. A total of 55.1% of grafts were ≤8 mm. Mixed-effects linear modeling revealed that height, weight, sex, and use of ≥5 strands correlated with graft size ( P < .001), while age did not. The predictive multivariate model based on the statistically relevant factors demonstrated a moderate correlation ( r = 0.39, R2 = 0.150), illustrated a predictive equation, and proved height to be the greatest determinant of graft size. Conclusion: Marked variability in graft size distribution was found among surgeons, and more than half of all grafts did not reach the ideal size for hamstring autograft ACL reconstruction. A predictive equation including anthropometric factors may be able to provide the expected graft size. The risk of early graft failure may be mitigated with preoperative consideration of anthropometric factors—most importantly, height—in preparation for possible augmentation, additional strands, or alternative graft sources.

scholarly journals Allograft Augmentation of Hamstring Anterior Cruciate Ligament Grafts is Associated with Increased Graft Failure

2018 ◽  
Vol 6 (7_suppl4) ◽  
pp. 2325967118S0014
Author(s):  
Crystal Perkins ◽  
Michael T. Busch ◽  
Melissa A. Christino ◽  
S. Clifton Willimon
Keyword(s):  
Soft Tissue ◽  
Acl Reconstruction ◽  
Graft Failure ◽  
Activity Level ◽  
Population Characteristics ◽  
Hamstring Autograft ◽  
Inclusion Criteria ◽  
Graft Rupture ◽  
Graft Diameter

Objectives: ACL reconstruction in adolescents is commonly performed with hamstring autografts. In the adolescent population with very high activity levels, graft rupture is the most feared complication of ACL reconstruction. Young age, higher activity level, allografts, and small graft diameter have been shown to be predictors of graft failure. The applicability of this data to pediatric ACL reconstructions is limited due to heterogeneity of ages, graft constructs, and tunnel techniques. The purpose of this study is to evaluate the association of soft tissue graft constructs and graft rupture following pediatric transphyseal ACL reconstruction. Our hypothesis is that allograft-augmentation of grafts is associated with an increased risk of graft rupture. Methods: A single-institution retrospective review was performed of consecutive patients. Inclusion criteria were age less than 20 years and transphyseal ACL reconstruction with hamstring autograft, with or without allograft augmentation. Graft constructs included 4-strand doubled semitendinosus and gracilis (4-STG), 5-strand tripled semitendinosus and doubled gracilis (5-STG), 6-strand doubled gracilis and semitendinosus plus allograft (6-STGAllo), and 7-strand tripled semitendinosus and doubled gracilis plus allograft (7-STGAllo). Exclusion criteria included multiligament reconstruction and less than 6 months follow-up. The primary outcome was graft rupture. Results: Three hundred fifty-five patients (157 males, 198 females) with an average age of 15.3 years were identified to meet inclusion criteria. Graft constructs included 4-STG (198), 5-STG (91), 6-STGAllo (65), and 7-STGAllo (1). Average graft diameter was 8.3 mm 4-STG, 8.9 mm 5-STG, and 9.2 mm 6-STGAllo. Age and graft sizes were significantly different across groups with older patients (p <0.001) and larger graft sizes (p <0.001) being found in patients with allograft-augmented grafts. Mean duration of follow-up was 26 months (range 6-56 months). There were 51 graft ruptures (14.3%). The failure rate of each construct was 13.6% 4-STG, 11.9% 5-STG, and 19.7% 6-STGAllo. Time to graft failure was 16 months (range 2-40 months), with 49% of failures occurring before 12 months and 24% after 24 months. Twenty-four patients (6.7%) had a contralateral ACL tear during the follow-up period. Table 1 provides population characteristics by graft rupture status. This data suggests that patients who sustain a graft rupture may be slightly younger (p=0.07) and have lower BMI (p=0.07) than those patients without graft rupture. Odds ratios for graft failure by graft construct, controlling for age and graft size were calculated. Patients with 6-STGAllo grafts had an odds ratio of 2.6 (95% CI: 1.02, 6.50) of graft rupture as compared to 4-STG. Conclusion: ACL reconstruction with hamstring autograft combined with soft tissue allograft have a 2.6 times risk of graft rupture as compared to hamstring autograft without augmentation. In situations where the surgeon harvests an inadequately sized 4-strand autograft, we recommend tripling the semitendinosus to produce a larger graft diameter rather than augment with an allograft.

scholarly journals ACL Reconstruction: Is There A Difference In Graft Motion For Bone-patellar Tendon-bone Vs Hamstring Autograft At 6 Weeks Post-operatively?

2014 ◽  
Vol 2 (7_suppl2) ◽  
pp. 2325967114S0004 ◽  
Author(s):  
James N. Irvine ◽  
Eric Thorhauer ◽  
Ermias Shawel Abebe ◽  
Scott Tashman ◽  
Christopher D. Harner
Keyword(s):  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Hamstring Autograft ◽  
Bone Patellar Tendon

scholarly journals SINGLE-LEG HOP TESTING AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IS NOT PREDICTIVE OF GRAFT RUPTURE IN ADOLESCENT PATIENTS

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0015
Author(s):  
Jie J Yao ◽  
Jordan Snetselaar ◽  
Gregory A. Schmale ◽  
Michael Saper
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
High Risk Population ◽  
Entire Cohort ◽  
Hop Tests ◽  
Graft Rupture ◽  
Adolescent Patients ◽  
The Mean ◽  
Anterior Cruciate

Background: Safe return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction is difficult to determine in adolescent patients. Return of strength and dynamic knee stability can be assessed with functional single-leg hop testing as part of a formal RTS assessment. However, it is unclear whether performance during single-leg hop testing can predict future ACL graft rupture. Hypothesis/Purpose: To investigate differences in single-leg hop testing between adolescent patients who experienced a graft rupture after ACL reconstruction and those that did not. Methods: A retrospective review of adolescent patients whom underwent primary ACL reconstruction with a hamstring (HS) autograft identified 16 patients (10 girls, 6 boys) with single-leg hop testing data prior to graft failure. A nearest neighbor match algorithm was used to age-, sex-, surgeon-, and graft-match 16 patients without graft rupture. All patients followed a standardized rehabilitation protocol following surgery. As part of a formal RTS test, assessment of function and dynamic strength/stability was performed using 4 different single-leg hop tests: single hop for distance, triple hop for distance, triple crossover hop for distance, and timed hop. The recovery of muscle strength was defined by a limb symmetry index (LSI) ≥ 90%. Bivariate analyses were performed to compare the two groups. Results: The mean age of the entire cohort at the time of surgery was 14.6 ± 1.5 years. Patients completed their RTS test at 29.0 ± 5.4 weeks. There were no statistically significant differences in demographics, graft size, or time to RTS test between groups. There were no statistically significant differences in LSIs on the single hop (p=0.90), triple hop (p=0.36), crossover hop (p=0.41), or timed hop (p=0.48). The mean LSIs on each of the four hop tests were 92.3 ± 14.7, 95.1 ± 6.1, 95.8 ± 7.1, and 98.6 ± 7.9, respectively. Passing rates were similar between groups (p=0.54). Conclusion: Performance on single-leg hop tests 6 months after surgery is not predictive of graft rupture following ACL reconstruction with HS autograft in adolescent patients. Further investigation of alternative RTS measures and different time frames for testing in this high-risk population is needed.

scholarly journals Hamstring autograft size importance in anterior cruciate ligament repair surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 93-97 ◽  
Author(s):  
Francisco Figueroa ◽  
David Figueroa ◽  
João Espregueira-Mendes
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Hamstring Autograft ◽  
Ligament Repair ◽  
Graft Size ◽  
Acl Surgery ◽  
Anterior Cruciate Ligament Repair ◽  
Anterior Cruciate ◽  
Graft Diameter

Graft size in hamstring autograft anterior cruciate ligament (ACL) surgery is an important factor directly related to failure. Most of the evidence in the field suggests that the size of the graft in hamstring autograft ACL reconstruction matters when the surgeon is trying to avoid failures. The exact graft diameter needed to avoid failures is not absolutely clear and could depend on other factors, but newer studies suggest than even increases of 0.5 mm up to a graft size of 10 mm are beneficial for the patient. There is still no evidence to recommend the use of grafts > 10 mm. Several methods – e.g. folding the graft in more strands – that are simple and reproducible have been published lately to address the problem of having an insufficient graft size when performing an ACL reconstruction. Due to the evidence presented, we think it is necessary for the surgeon to have them in his or her arsenal before performing an ACL reconstruction. There are obviously other factors that should be considered, especially age. Therefore, a larger graft size should not be taken as the only goal in ACL reconstruction. Cite this article: EFORT Open Rev 2018;3:93-97. DOI: 10.1302/2058-5241.3.170038

scholarly journals DIFFERENCES IN ACUTE POSTOPERATIVE PAIN AFTER ACL RECONSTRUCTION IN ADOLESCENT PATIENTS: ALL SOFT-TISSUE QUADRICEPS VERSUS HAMSTRING AUTOGRAFT

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0014
Author(s):  
Brandon Levy ◽  
Erica Holland ◽  
Viviana Bompadre ◽  
Gregory A. Schmale ◽  
Michael Saper
Keyword(s):  
Postoperative Pain ◽  
Soft Tissue ◽  
Acl Reconstruction ◽  
Quadriceps Tendon ◽  
Management Plan ◽  
Hamstring Autograft ◽  
Acute Postoperative Pain ◽  
Pain Scores ◽  
Adolescent Patients ◽  
Tendon Autograft

Background: Postoperative pain after anterior cruciate ligament (ACL) reconstruction is a subjective experience that contributes significantly to patient satisfaction and subjective outcomes. As such, it is important for surgeons to counsel their patients and set appropriate expectations following surgery. ACL reconstruction with hamstring (HS) tendon autograft remains the most popular graft choice in adolescent patients with open physes, yet recently, reconstruction using all soft-tissue quadriceps tendon autograft has gained in popularity. However, studies are lacking that evaluate acute postoperative pain after quadriceps autograft. Hypothesis/Purpose: To investigate differences in acute postoperative pain between adolescent patients undergoing ACL reconstruction with all soft-tissue quadriceps versus HS autograft. Methods: A retrospective review was performed of 65 patients that underwent primary ACL reconstruction using either quadriceps (n = 33) or HS (n = 32) autografts between October 2017 and April 2019. All patients received ultrasound-guided adductor canal catheters and single-shot sciatic nerve blocks preoperatively and followed a standard postoperative multi-modal pain management plan. Intraoperative and postoperative intravenous (IV) morphine equivalents (MEQ), post-anesthesia care unit (PACU) length of stay (LOS), and PACU pain scores (numeric rating scale, 0-10) were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. Results: The mean age at the time of surgery was 15.2 ± 1.5 years. There were no statistically significant differences in age ( p = 0.62), sex ( p = 0.72), BMI ( p = 0.18), concomitant meniscus repairs ( p = 0.71), or surgical time ( p = 0.52) between the two groups. There were no statistically significant differences in intraoperative IV MEQs ( p = 0.44), PACU IV MEQ ( p = 0.43), or PACU LOS ( p = 0.47) between the two groups. Patients treated with quadriceps autograft has lower max PACU pain scores (3.2 ± 3.2 vs 4.1 ± 3.1; p = 0.27) and required less supplemental oxycodone doses on POD 1 (1.1 ± 1.2 vs 1.8 ± 1.6; p = 0.07) but the differences were not statistically significant. Max pain scores (at rest and with movement) on POD 1-3 and oxycodone use on both POD 2 and POD 3 were similar between groups. Conclusion: In the setting of a multi-modal pain management plan including regional anesthesia, adolescent patients undergoing ACL reconstruction with quadriceps tendon autograft and hamstring autograft have similar pain levels and opioid use in the acute postoperative period.

scholarly journals Augmentation of Primary ACL Reconstruction With a Modified Ellison Lateral Extra-articular Tenodesis in High-Risk Patients: A Pilot Study

2021 ◽  
Vol 9 (8) ◽  
pp. 232596712110213
Author(s):  
Julian A. Feller ◽  
Brian M. Devitt ◽  
Kate E. Webster ◽  
Haydn J. Klemm
Keyword(s):  
High Risk ◽  
Acl Reconstruction ◽  
Rating Scale ◽  
Cruciate Ligament ◽  
Positive Family History ◽  
Case Series ◽  
Return To Sport ◽  
Acl Graft ◽  
Graft Rupture ◽  
Primary Acl Reconstruction

Background: Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment. Purpose: To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Included were 25 consecutive patients with at least 2 of the following risk factors: age <20 years at the time of surgery, previous contralateral ACL reconstruction, positive family history of ACL rupture (parent or sibling), generalized ligamentous laxity (Beighton ≥4), grade 3 pivot shift in the consulting room, a desire to return to a pivoting sport, and an elite or professional status. All patients underwent primary ACL reconstruction with an additional modified Ellison procedure. Postoperatively, patients completed the IKDC subjective knee evaluation form (International Knee Documentation Committee), KOOS Quality of Life subscale (Knee injury and Osteoarthritis Outcome Score), ACL–Return to Sport After Injury Scale, Marx Activity Rating Scale, and SANE score (Single Assessment Numeric Evaluation). Results: At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL–Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months. Conclusion: The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.

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