COA Symposium: Sports - Current Concepts in Graft Choice for ACL Reconstruction

OrthoMedia ◽  
2022 ◽  
Keyword(s):  
Acl Reconstruction ◽  
Graft Choice

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 Machine learning algorithm to predict anterior cruciate ligament revision demonstrates external validity

2022 ◽  
Author(s):  
R. Kyle Martin ◽  
Solvejg Wastvedt ◽  
Ayoosh Pareek ◽  
Andreas Persson ◽  
Håvard Visnes ◽  
...  
Keyword(s):  
Machine Learning ◽  
Acl Reconstruction ◽  
External Validity ◽  
Learning Algorithm ◽  
Cruciate Ligament ◽  
External Validation ◽  
Model Performance ◽  
Knee Ligament ◽  
Graft Choice ◽  
Anterior Cruciate

Abstract Purpose External validation of machine learning predictive models is achieved through evaluation of model performance on different groups of patients than were used for algorithm development. This important step is uncommonly performed, inhibiting clinical translation of newly developed models. Machine learning analysis of the Norwegian Knee Ligament Register (NKLR) recently led to the development of a tool capable of estimating the risk of anterior cruciate ligament (ACL) revision (https://swastvedt.shinyapps.io/calculator_rev/). The purpose of this study was to determine the external validity of the NKLR model by assessing algorithm performance when applied to patients from the Danish Knee Ligament Registry (DKLR). Methods The primary outcome measure of the NKLR model was probability of revision ACL reconstruction within 1, 2, and/or 5 years. For external validation, all DKLR patients with complete data for the five variables required for NKLR prediction were included. The five variables included graft choice, femur fixation device, KOOS QOL score at surgery, years from injury to surgery, and age at surgery. Predicted revision probabilities were calculated for all DKLR patients. The model performance was assessed using the same metrics as the NKLR study: concordance and calibration. Results In total, 10,922 DKLR patients were included for analysis. Average follow-up time or time-to-revision was 8.4 (± 4.3) years and overall revision rate was 6.9%. Surgical technique trends (i.e., graft choice and fixation devices) and injury characteristics (i.e., concomitant meniscus and cartilage pathology) were dissimilar between registries. The model produced similar concordance when applied to the DKLR population compared to the original NKLR test data (DKLR: 0.68; NKLR: 0.68–0.69). Calibration was poorer for the DKLR population at one and five years post primary surgery but similar to the NKLR at two years. Conclusion The NKLR machine learning algorithm demonstrated similar performance when applied to patients from the DKLR, suggesting that it is valid for application outside of the initial patient population. This represents the first machine learning model for predicting revision ACL reconstruction that has been externally validated. Clinicians can use this in-clinic calculator to estimate revision risk at a patient specific level when discussing outcome expectations pre-operatively. While encouraging, it should be noted that the performance of the model on patients undergoing ACL reconstruction outside of Scandinavia remains unknown. Level of evidence III.

scholarly journals Meniscal Repair with Concurrent Anterior Cruciate Ligament Reconstruction: Is ACL Graft Choice Predictive of Meniscal Repair Success?

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0035
Author(s):  
Hytham S. Salem ◽  
Laura J. Huston ◽  
Alex Zajichek ◽  
Michelle Lora Wolcott ◽  
Eric C. McCarty ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Meniscal Tear ◽  
Meniscal Repair ◽  
Acl Graft ◽  
Baseline Activity ◽  
Graft Choice ◽  
Significant Difference ◽  
Anterior Cruciate

Objectives: The success rate of meniscal repair is known to increase with concurrent anterior cruciate ligament (ACL) reconstruction. However, the influence of ACL graft choice has not been described. The current study examines the effect of ACL graft choice on the outcome of meniscal repair performed in conjunction with ACL reconstruction (ACLR). Methods: Patients who underwent meniscal repair with concurrent primary ACLR were identified from a longitudinal, prospective cohort. Patient demographics and subjective outcome measures including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale were collected preoperatively. Arthroscopic assessment of meniscal tear characteristics and associated repair technique were recorded intraoperatively. Patients with subsequent repair failure, defined as any subsequent surgical procedure addressing the meniscus repaired at index surgery, were identified and operative notes were obtained in order to accurately classify pathology and treatment. A logistic regression model was built to assess the association of patient specific factors, ACL graft, baseline Marx activity level and meniscal tear laterality with the occurrence of repair failure at 6-year follow-up. Results: A total of 646 patients underwent ACLR with concurrent meniscal repair. Bone-patellar tendon-bone (BTB) and soft tissue (ST) autograft were used in 55.7% and 33.9% of cases, respectively, while allografts were utilized in the remaining cases. Table 1 summarizes the univariate analysis of each baseline variable. A total of 101 patients (15.6%) required subsequent surgery on the meniscus repaired at index surgery, including 89 meniscectomies (87 partial, 2 subtotal), 11 revision meniscal repairs, and 1 meniscus allograft transplantation. No statistically significant difference in meniscal repair failure rate was observed based on patient age, sex, BMI or smoking status. The odds of meniscal repair failure within 6 years of surgery for patients with only a lateral meniscal repair are 68% less than those with only a medial meniscal repair (CI: 41%, 83%; p<0.001). There is a statistically significant relationship between baseline Marx activity and the risk of subsequent meniscal repair, though it is nonlinear—patients with low or high baseline activity are at the highest risk of meniscal repair failure (CI: 1.05,1.31; p=0.004, Figure 1). The estimated odds of meniscal repair failure for BTB allograft, ST allograft, and ST autograft were 2.78 (CI: 0.84,9.19; p=0.09), 2.29 (CI: 0.97,5.45; p=0.06), and 1.42 (CI:0.87,2.32; p=0.16) times that of BTB autograft, respectively, although none proved statistically significant. Meniscal repair failure is associated with significantly lower 6-year scores for all KOOS components and the IKDC (p<0.001). However, there was no significant difference in MARX activity at 6-years (p=0.27). Conclusion: In the setting of primary ACLR, the risk of meniscal repair failure is increased with medial versus lateral meniscal repair. Patients with low or high baseline activity levels are also at an increased risk. ACL graft choice seems to have an effect on meniscal repair failure that approaches but does not reach statistical significance. A larger sample size may be required to accept the null hypothesis. [Table: see text][Figure: see text]

scholarly journals COMPARISON OF BONE-PATELLA TENDON-BONE (BTB) AND QUADRICEPS AUTOGRAFT FOR ACL RECONSTRUCTION IN PATIENTS UNDER 18 YEARS OF AGE

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0027
Author(s):  
Seth L. Sherman ◽  
Daniel W. Hogan ◽  
Derek W. Geeslin ◽  
Joseph M. Rund ◽  
M. Benjamin Burch ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Patient Population ◽  
Patient Reported Outcomes ◽  
Skeletal Maturity ◽  
Surgical Patient ◽  
Cartilage Restoration ◽  
Graft Choice ◽  
Patient Reported ◽  
Subjective Outcomes

Background: Graft choice for ACL reconstruction in patients under 18 years old remains controversial. BTB autograft has long been considered for young athletes who are at or near skeletal maturity. Quadriceps autograft has emerged as an alternative graft choice in the young patient population. However, there remains a paucity of comparative outcomes. Hypothesis/Purpose: Our purpose is to compare subjective outcomes and complications of ACL reconstruction in patients under 18 years old using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complication between groups. Methods: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients under 18 years old undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (i.e., infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. Results: 71 patients met inclusion criteria. There were 41 BTB and 30 quadriceps autografts. Mean age was 16.5 years in the BTB group and 14.5 in the quadriceps group (p=0.0000006). 27 of 41 (66%) BTB and 13 of 30 (43%) quadriceps were female. There were no significant differences in PROs between groups. At minimum 6-month follow-up (range 6-25.7 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in IKDC scores (31.10%, p=0.0009; 34.25%, p=0.00000008), all KOOS domains, SANE (41.80%, p=0.0000006; 42.42%, p=0.000000002), and Tegner scores (2.99%, p=0.0002; 3.35%, p=0.000004). Post-operative PROs were not significantly different between groups (p>0.05). Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required 3 post-operative re-operations (10% and 7%, p=0.7), each group including 2 revision reconstructions (7% and 5%, p=0.8) and 1 procedure for stiffness (3% and 2%, p=0.8). Conclusion: For ACL reconstruction in patients under 18 years old, both BTB and quadriceps autografts demonstrated significant subjective improvements and low rates of complications requiring re-operation. Quadriceps autograft appears to be a safe and effective alternative to BTB autograft in this challenging patient population. [Table: see text][Table: see text]

scholarly journals NZ ACL Registry 2016 Annual Report

2017 ◽  
Vol 5 (5_suppl5) ◽  
pp. 2325967117S0017
Author(s):  
Hamish Love
Keyword(s):  
New Zealand ◽  
Acl Reconstruction ◽  
Annual Report ◽  
Demographic Data ◽  
Failure Rates ◽  
Operative Data ◽  
Graft Choice ◽  
Outcome Scores

Objectives: Presentation of the cumulative results of the first 2 years of the New Zealand ACL registry. Methods: The NZ ACL registry aims to collect relevant data for all patients undergoing ACL reconstruction in New Zealand. Injury and demographic data is collected. Marx activity and KOOS scores are recorded pre-operatively, and at 6,12 and 24 months postoperatively. Operative data is including chondral and meniscal injuries, implant choice, graft choice and diameter and concomitant procedures are recorded. Results: Demographic data. Patterns of technique and implant utilization. Outcome scores, complication and failure rates for the 2,500 patients currently enrolled in the registry will be presented. Conclusion: This report will contain the cumulative results of the NZ ACL Registry for the first full two years of it’s operation.

scholarly journals Hamstring Strength Recovery is Worse in Women than Men following ACL Reconstruction with Hamstring Autografts

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0035
Author(s):  
Stephan G. Bodkin ◽  
Aaron Joseph Casp ◽  
Michelle Elizabeth Kew ◽  
Stephen F. Brockmeier ◽  
David R. Diduch ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Knee Extensor ◽  
Return To Sports ◽  
Knee Flexor ◽  
Cohen’S D ◽  
Strength Recovery ◽  
Bptb Graft ◽  
Graft Choice ◽  
Cohen's D

Objectives: Graft choice in ACL reconstruction (ACLR) and post-operative rehabilitation may influence strength recovery and return to sports differently in men versus women. Persistent muscle weakness, impaired function, and poor patient reported outcomes are a concern for patients early after reconstruction and impact a timely and successful return to unrestricted physical activity without re-injury. However, little is known about the effect of graft choice and sex on short term ACLR recovery and return-to-play assessment. The purpose of this study was to compare knee extensor and flexor strength between male and female patients in isolated ACLR across both patellar tendon and hamstring autografts. Methods: A total of 166 patients with primary, unilateral and uncomplicated ACL reconstructions (22.6±9.9 years, 87 females, 5.94±.46 months post ACLR) were recruited for participation. There were 100 patients with bone patellar tendon bone (BPTB) autografts and 66 hamstring (HS) autografts. All patients completed the Tegner activity Scale and underwent bilateral isokinetic (90°/sec) tests of the knee extensor and flexor groups. Outcomes were recorded in a single session as part of a return-to-sport test battery. Strength was expressed as torque normalized to mass (Nm/kg) and limb-symmetry was expressed as a percentage of (involved/uninvolved)*100. Surgical Notes were obtained to determine the patient’s sex and type of autograft used at the time of ACLR. Strength measures were compared using 2x2 ANCOVAs (Sex by Graft Type) with the patient’s current activity level as a covariate. Post-hoc Cohen’s D effect sizes and 95% CI were calculated and statistical significance was defined as p-values of .05 or less. Results: There was a significant sex*graft type interaction for normalized knee flexor torque (P=.017) (Figure 1). Females with a HS graft (.592±.49 Nm/kg) had significantly less knee flexor torque compared to females with a BPTB graft (.910±.24 Nm/kg, Cohen’s d= .90[.45, 1.36]) and all males (HS: .937±.35, Cohen’s d=.87 [.45, 1.30]). There were significant main effects for graft type for knee flexor (P=.001) and extensor (P=.008) symmetry. Patients with a BPTB graft demonstrated less knee extensor symmetry (65.7±17%) and greater knee flexor symmetry (98.7±18%) compared to patients with a HS graft (Extension: 77.1±32%, Cohen’s d=.47[.16, .79]) (Flexion: 82.9±33%, Cohen’s d=.63[.31,.95]). We also observed a significant main effect for sex (P=.028) and graft type (P=.048) for normalized knee extensor strength. On average, males (1.67±.60 Nm/kg) demonstrated significantly greater normalized extensor torque than females (1.44±.75 Nm/kg, Cohen’s d= .34 [.03, .64]), and patients with a HS graft (1.66±.34 Nm/kg) demonstrated greater normalized extensor strength than those with a BPTB graft (1.45±.42 Nm/kg, Cohen’s d= .54 [.22, .85]). Conclusion: At approximately 6 months following ACLR, female patients reconstructed with hamstring autografts demonstrated weaker hamstring strength compared to females with a BPTB autograft. There were no differences in hamstring strength between graft types in males. Females appear to be recovering hamstring strength differently than males when using a hamstring autograft. These findings may have implications in surgical planning, post-operative rehabilitation and return to sports decision making. [Figure: see text]

scholarly journals Anterior Cruciate Ligament Graft Choices: A Review of Current Concepts

2012 ◽  
Vol 6 (1) ◽  
pp. 281-286 ◽  
Author(s):  
Sujay K Dheerendra ◽  
Wasim S Khan ◽  
Rohit Singhal ◽  
Deepak G Shivarathre ◽  
Ravi Pydisetty ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Meta Analysis ◽  
Hamstring Tendon ◽  
Anterior Cruciate Ligament Graft ◽  
Graft Choice ◽  
Anterior Cruciate ◽  
Synthetic Grafts ◽  
Comparative Trials

The graft choice for anterior cruciate ligament (ACL) reconstruction continues to be controversial. There are several options available for the treating surgeon, including Bone Patellar Tendon Bone (BPTB) grafts, Hamstring tendon (HT) grafts, allografts and synthetic grafts. Within the last decade there have been several comparative trials and meta-analysis, which have failed to provide an answer with regards to the best graft available. The aim of this review is to understand the current concepts in graft choices for ACL reconstruction.

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