Current evidence around patellar tendon graft in ACLR for high-risk patients: current concepts

Hamstrings and patellar tendon (PT) are the most common autografts used to perform anterior cruciate ligament (ACL) reconstructions. The debate to know which graft should be better has been going on for decades. However, in relation to underpowered studies, no strong conclusions have been drawn until recently. Indeed, there was a need for a greater magnitude of data and assessment of specific population to properly compare these grafts. Our objective was to provide a current review based on recent scientific publications with high level of evidence. Registries have provided conclusive information. The Scandinavian registry showed lower failure rate for bone–patellar tendon–bone (BPTB) versus hamstring tendon (HT) at 5-year follow-up in over 45 000 patients (2.8% vs 4.2%; p<0.001). In the Norwegian registry, with 12 643 patients included, higher revision rates were recorded in HT graft versus BPTB graft at all follow-up times (2.8% vs 0.7% at 2 years and 5.1% vs 2.1% at 5 years). Moreover, as far as high-risk profile patients were concerned, this difference was even more significant. This trend has also been confirmed more recently in a study when assessing young females, showing that the failure rate amounted to 6.4% in the PT group while it reached 17.5% in the HT group at 3.7-year follow-up (p=0.02). ACL graft selection should be a discussion between the physician and the patient, taking into consideration age, activity level and occupation. Within the high-risk patient group however, scientific evidence supports the PT as the gold standard for ACL reconstruction.

COMPARATIVE STUDY OF ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING BONE PATELLAR TENDON BONE GRAFT AND HAMSTRING GRAFT

INTRODUCTION: ACL reconstruction is probably the most common procedure of the knee in adults in recent times, and the choice of graft to be used for it is the most important decision to be made during the surgery.Although several methods of ACL reconstruction exist,the 2 most common procedures done are BTB reconstruction using an autograft of the middle third of the patellar tendon and reconstruction using a (HT) graft. PURPOSE: The purpose of this study was to evaluate the midterm functional outcome of ACL reconstruction using the bone-patellar tendon-bone graft and hamstring graft. MATERIALS AND METHODS: The study was conducted in the Department of Orthopaedics,Kempegowda institute of medical science and research centre.A total of 40 cases were operated out of whom 20 were operated using arthroscopic ACL reconstruction using Hamstring graft and other 20 underwent ACLR using Patellar tendon graft.Patients in our study were assessed by IKDC,Tegners and Lysholm operative scores. RESULTS- The mean age of the patients in our study was around 29 years. Around 70% of our patients were operated within 6 months from the time of injury after achieving complete flexion. Evaluation using IKDC, Lyshom and tegner scoring system showed hamstring graft having statistical significance when compared with BPTB graft, but the difference between the groups was not clinically appreciable. CONCLUSIONS: ACL reconstruction by either hamstring tendon graft or bone patellar tendon graft gives equally satisfactory results.But complications in the form of anterior knee pain were noted in BPTB group

Effect of Graft Choice on Revision and Contralateral Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry

Background: The patellar tendon is often considered the “gold standard” graft for reducing the risk of graft rupture after anterior cruciate ligament (ACL) reconstruction. However, its use may also be associated with an increased risk of injury to the contralateral ACL. Purpose: To clarify the association between graft choice and the risk of revision and contralateral ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Prospective data captured by the New Zealand ACL Registry between April 2014 and December 2018 were reviewed. All primary ACL reconstructions performed using either a hamstring tendon or patellar tendon autograft were included. Cox regression survival analysis adjusting for patient factors was performed to compare the risk of revision and contralateral ACL reconstruction between the hamstring tendon graft and the patellar tendon graft. Results: A total of 7155 primary ACL reconstructions were reviewed, of which 5563 (77.7%) were performed using a hamstring tendon graft and 1592 (22.3%) were performed using a patellar tendon graft. Patients with a hamstring tendon graft had a revision rate of 2.7% compared with 1.3% in patients with a patellar tendon graft (adjusted hazard ratio [HR], 2.51; 95% CI, 1.55-4.06; P < .001). The patellar tendon graft was associated with an increased risk of contralateral ACL reconstruction compared with the hamstring tendon graft (adjusted HR, 1.91; 95% CI, 1.15-3.16; P = .012). The number needed to treat (NNT) with a patellar tendon graft to prevent 1 revision was 73.6. However, the NNT with a hamstring tendon graft to prevent 1 contralateral reconstruction was 116.3. Conclusion: Use of a patellar tendon graft reduced the risk of graft rupture but was associated with an increased risk of injury to the contralateral ACL. Adequate rehabilitation and informed decision making on return to activity and injury prevention measures may be important in preventing subsequent injury to the healthy knee.

Review of Jones (1963) on ‘Reconstruction of the anterior cruciate ligament. A technique using the central one-third of the patellar ligament’

This classic discusses the original publication ‘Reconstruction of the anterior cruciate ligament (ACL). A technique using the central one-third of the patellar ligament’ on the Jones procedure. Published in 1963 in the ‘Journal of Bone and Joint Surgery American Volume’, it was inspired by pioneering surgeons in the field of knee ligament reconstruction. Jones introduced a technique that reconstructed the ACL using the middle third of the patella tendon, leaving it attached to a strip of patella and quadriceps tendon to obtain the necessary length. The strip of patellar tendon was then introduced and secured in a tunnel drilled in an inside-out fashion through the lateral femoral condyle. Although with time technological advances and clinical and biomechanical studies led to profound modifications of the technique described in the original article, the concepts introduced by Jones are still at the base of all the reconstructive techniques of the ACL using a patellar tendon graft.

Relationship Between Physical Therapy Characteristics, Surgical Procedure, and Clinical Outcomes in Patients After ACL Reconstruction

Context: Postoperative rehabilitation is critical to optimize outcomes after anterior cruciate ligament reconstruction (ACLR). However, the relationship between physical therapy (PT) and clinical outcomes is unclear. Objective: To describe PT characteristics following ACLR and to assess the relationships between PT characteristics, surgical procedure, and clinical outcomes. Design: Cross-sectional. Setting: Laboratory. Patients (or Other Participants): A total of 60 patients (31 females/29 males, age = 22.4 [9.2] y, height = 171.7 [9.9] cm, and mass = 70.2 [14.7] kg) with a history of primary unilateral ACLR (53.6% patellar tendon and 46.4% hamstring) participated. Intervention(s): Patients completed a performance assessment and rated subjective knee function prior to physician clearance (mean = 6.3 [1.3] mo postoperatively) and were contacted within 6 months of clearance to complete a PT questionnaire. Main Outcome Measures: PT questionnaire item response, knee extension maximum voluntary isometric contraction (MVIC) torque, peak isokinetic knee extension torque, single leg hop distance, and International Knee Documentation Committee were measured. Correlations assessed relationships between PT quantity and clinical outcomes. Independent t tests compared PT quantity and clinical outcomes based on return-to-sport status, readiness to return to sport, and surgical procedure. Results: Patients completed regular PT (2 d/wk, 25 wk, 58 visits) and were most likely to conclude when discharged by the therapist (68.3%). More than half (56.7%) returned to sport, yet most (73.3%) felt unready at discharge. Isokinetic torque was correlated with days of PT/week (r = .29, P = .03). Isokinetic torque and hop symmetry were reduced in patients who returned to sport (P < .05). Patients who felt ready to return completed fewer weeks of PT (P < .05). Patients with a patellar tendon graft completed more days of PT/week and total visits, but demonstrated lower MVIC torque, MVIC symmetry, and isokinetic symmetry (P < .05). Conclusions: Many patients felt unready to return to sport at PT discharge. PT frequency was associated with isokinetic torque, yet this relationship was small. Outcomes were reduced in patients who returned to sport, suggesting premature resumption of preinjury activity.