Transcript A comparison of functional outcomes after anterior
Comparing Outcomes after Anterior Cruciate Ligament Reconstruction using either Patellar or Hamstring Tendon Autografts: A Systematic Review By Michael Sheridan and Are Martin Kallaak
Glossary
ACL – Anterior Cruciate Ligament BPTB – Bone-Patellar-Tendon-Bone IKDC – International Knee documentation Comittee ST – Semitendinosus STG – Semitendinosus Gracilis CONSORT – Consolidated Statement for Reporting Trials
ACL reconstructive surgery
In USA about 50 000 to 75 000 ACL reconstructions are performed each year
ACL reconstructive surgery
Involves replacing the torn ACL with graft tissue
ACL reconstructive surgery
Autograft= Graft tissue harvested from patients own body Allograft= Graft tissue harvested from cadaver
ACL reconstructive surgery
Most commonly Autografts is harvested from the Patellar tendon or the Semitendinosus and/or Gracilis tendons
ACL reconstructive surgery
ACL reconstructive surgery
Preparation of ST/G graft
ACL reconstructive surgery
Most ACL surgeries today are performed arthroscopically
ACL reconstructive surgery
Introduction
BPTB grafts has been considered the golden standard
Introduction
There exists little evidence to support this
Introduction
Previous studies have found no significant differences between BPTB and ST/G grafts
Introduction
Current level of evidence is inconsistent regarding best overall outcomes
Objective
To investigate if there is a significant difference between the two techniques 0 hypothesis= There is a significant difference favoring use of BPTB graft Hypothesis= There is no significant difference between the 2 techniques.
Research question
Is there a difference in outcomes of knee scoring systems after ACL reconstruction using either Patellar or Hamstring tendon grafts?
Methods
Literature search Medline and Google Scholar Keywords used: ACL reconstruction, Patellar, Hamstring, Functional Outcomes, Clinical Trial, IKDC, Lysholm and Cincinnatti
Methods
Outcome Measurements IKDC (International Knee documentation Scale) Lysholm Tegner activity scale Cincinnati KT-1000
Methods
Inclusion criteria English language Published within last 10 years IKDC, Lysholm, Tegner or Cincinatti as outcome measures Randomized studies only At least 2 year follow up Identical mode of rehabilitation within each article Artroscopic intervention Score 80% or higher on the CONSORT checklist for RCT’s Hamstring and Patellar grafts is compared directly
Methods
Methods
Evaluation of studies CONSORT checklist for RCT’s 80% was required For inclusion randomization needed to be described according to CONSORT
Methods
IKDC Valid and reliable widely used knee evaluation questionnaire
Methods
IKDC Consists of an objective and subjective part
Methods
IKDC Scoring: A- Normal Function B- Nearly Normal C- Abnormal D- Severely Abnormal
Methods
Lysholm Knee Rating System 1 page scoring sheet
Methods
Lysholm Knee Rating System Filled out by patient
Methods
Lysholm Knee Rating System Proven reliable as a one time measurement but not for detecting changes over time
Methods
Lysholm Knee Rating System Total score of 100 points possible
Methods
Methods
Cincinnati Found to be valid and reliable useful for detecting changes between evaluations
Methods
Tegner activity scale simple 10 point rating scale Good level of test-retest reliability and responsiveness
Methods
KT-1000 arthrometer Instrument to measure knee ligament laxity in the saggital plane Consistency of measurements of anterior knee laxity between examiners is considered as fair to moderate
Results
17 articles where judged relevant for our topic After our inclusion criteria was applied we were left with 10 After Evaluation with the CONSORT checklist 7 articles were left for inclusion
Results
Since only RCT’s were included the randomization process needed to be described in detail
Results
Included articles Aglietti P, Biddau F, Buzzi R, Giron F, Sasso F, 2004, Anterior Cruciate Ligament Reconstruction:
Bone-Patellar-Tendon-Bone compared with Double Semitendinosus and Gracilis Tendon Grafts.
A Prospective Randomized Clinical Trial, J. Bone and Joint Surgery 86: pp 2143-2155 Al-Kussary I M, Al-Misfer A R K, Al- Mutairi H Q, Ghafar S A, Ibrahim S A R, Noor T A E, 2005,Clinical
evaluation of Arthroscopically assisted anterior cruciate ligament reconstruction: Patellar
tendon versus Gracilis and semitendinosus autograft, The Journal of Arthroscopy and Related Surgery 21,4:pp 412-417 Aune A K, Holm I, Krogstad Jensen H, Risberg M A, Steen H, 2001, Four-Strand Hamstring Tendon
Autograft Compared with Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament
Reconstruction: A Randomized Study with Two Year Follow-Up, The American Journal of Sports Medicine, Vol. 29, No.6: pp 722-728 Ejerhed L, Kartus J Karlsson J, Köhler K, Sernert N, 2003, Patellar Tendon or Semitendinosus
Tendon Autografts for Anterior Cruciate Ligament Reconstruction? A Prospective Randomized
Study with a Two Year Follow-Up, The American Journal of Sports Medicine, Vol 31, No.1: pp 19-25 Feller J A, Webster K E, 2003, A Randomized Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine Vol.31, No. 4:pp 564-573 Harilainen A, Jansson K A, Linko E, Sandelin J, 2003, A prospective randomized study of Patellar versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine, Vol. 31, No. 1:pp 12-18 Laxdal G, Hansson L, Heidvall M, Karlsson J, Kartus J, Ejerhed L, 2005 , A prospective randomized
comparison of bone-patellartendon-bone and hamstring grafts for anterior cruciate ligament
reconstruction, The Journal of Arthroscopy and Related Surgery 21,1:pp 34-42
Results
Total patient population
700 600 500 400 300 200 100 0
BPTB ST STG Aglietti, Al-Kussary, Aune, Ejerhed, Feller, Harilainen, Laxdal 272 Aglietti, Aune, Ejerhed, Feller, Harilainen, Laxdal 245 Al-Kussary, Laxdal 84 Total 626
Results
Lysholm Scores
100 90 80 70 60 50 40 30 20 10 0 Laxdal Ejerhed Harilainen Al-Kussary mean score BPTB Pre-op HT Pre-op BPTB Post-op HT Post-Op
Results
Mean Tegner scores at 2 year Follow–up. 4 articles.
10 9 8 7 6 5 4 3 2 1 0 BPTB ST STG Laxdal Ejerhed Harilainen Al-Kussary Mean Score
No statistically significant differences between groups.
Results
3
Mean side to side anterior laxity at ≥ 2 year follow-up. KT1000
2.5
2 1.5
1 0.5
0
BPTB ST STG Fe lle r 1.1
1.7
Aune 2.7
2.7
Eje rhe d 2005 Eje rhe d 2003 1 2 1 2 2.25
Aglie tti 1.95
2.2
Al-Kus s ary 1.95
2.2
Results
Cincinnati functional score
Aune et al (2001) was the only article to use the Cincinnati functional score but reported no difference between the groups
Results
IKDC
1.
Used in 5 of 7 articles.
2.
No statistically significant differences between groups.
3.
2 studies reported that no patients scored D (severely abnormal) in either group
Results: summing up the outcome measures.
1.
2.
3.
4.
5.
BPTB IKDC = no difference between other graft types.
Cincinnati = no difference between the groups.
Tegner = scoring higher than ST but lower than STG.
Lysholm = Highest scoring, not clinically significant.
KT 1000 = same average score as STG and slightly better than ST. No significance
Results: summing up the outcome measures.
1.
2.
3.
4.
5.
ST IKDC = no difference between other graft types.
Cincinnati = no difference between the groups.
Tegnor = Lowest scoring. No significance Lysholm = Lowest scoring, not clinically significant.
KT 1000 =Highest laxity Score. No significance
Results: summing up the outcome measures.
1.
2.
3.
4.
5.
STG IKDC = no difference between other graft types.
Cincinnati = no difference between the groups.
Tegnor = Highest scoring. No significance Lysholm = No Values KT 1000 =less laxity than ST group, same score as BPTB. Differences not significant.
Results
Patellafemoral symptoms 5 studies reported that kneeling pain was significantly more common in the BPTB group
Results
Patellafemoral symptoms Not to be confused with anterior knee pain which showed no difference between the groups at 2 year follow up
Discussion
No significant difference found with any of the knee scoring systems
Discussion
Graft type is not the only factor affecting outcomes Factors not evaluated by our outcome measures may reveal significant differences
Discussion
External validity and RCT’s ACL reconstructions under different circumstances occur but are never included in randomized trials Skill and experience of the surgeon
Discussion
Limitations of this review not considering differences in fixation methods between studies Variations in rehabilitation between studies Not enough high quality RCT’s with identical methodology
Discussion
What could be done to improve the level of evidence?
larger population Longer follow up Comparing other factors related to ACL Difficult to achieve
Conclusion
The use of BPTB as the golden standard is not backed up by sufficient evidence Both techniques shows significant improvement in outcomes
Clinical Significance
The patellar tendon graft is not recommended for: people requiring a lot of kneeling in daily life Athletes that are involved in sports that puts a lot of strain on the patellar tendon
Clinical Significance
Due to slightly better stability associated with the BPTB graft it may be recommended for athletes involved in sports that require a lot of pivoting and twisting.
ST/G grafts is recommended for patients with patellafemoral problems
Clinical Significance
The PT together with the patient should perform an evaluation of the individual needs in order to find what graft type is best
Aknowledgements
We would like to thank: Our coach Jesse Aarden and our client Niels Veeldhuijzen for their assistance and expertise We are also thankful to the facilities of VU Amsterdam for supplying access to scientific articles
Aglietti P, Biddau F, Buzzi R, Giron F, Sasso F, 2004, Anterior Cruciate Ligament Reconstruction: Bone-Patellar-Tendon-Bone compared with Double Semitendinosus and Gracilis Tendon Grafts. A Prospective Randomized Clinical Trial, J. Bone and Joint Surgery 86: pp 2143-2155 Al-Kussary I M, Al-Misfer A R K, Al- Mutairi H Q, Ghafar S A, Ibrahim S A R, Noor T A E, 2005,Clinical evaluation of Arthroscopically assisted anterior cruciate ligament reconstruction: Patellar tendon versus Gracilis and semitendinosus autograft, The Journal of Arthroscopy and Related Surgery 21,4:pp 412-417 Aune A K, Holm I, Krogstad Jensen H, Risberg M A, Steen H, 2001, Four-Strand Hamstring Tendon Autograft Compared with Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction: A Randomized Study with Two Year Follow-Up, The American Journal of Sports Medicine, Vol. 29, No.6: pp 722-728 Aune A K, Cawley P W, Ekeland A, 1998, Interference screw fixation of hamstring vs patellar tendon grafts for anterior cruciate ligament reconstruction; Knee surgery, Sports traumatology, Arhtroscopy 6:pp 99-102 Ballantyne B T, French A K, Heimsoth S L , Kachingwe A F, Lee J B, Soderberg G L, 1995, Influence of examiner experience and gender on interrater reliability of KT-1000 arthrometer measurements, Physical Therapy Vol. 75, No. 10, October 1995, pp. 898-906 Barber-Westin S, Noyes F, McCloskey J.W, 1999 ; Rigorous Statistical Reliability, Validity, and Responsiveness Testing of the Cincinnati Knee Rating System in 350 Subjects with Uninjured, Injured, or Anterior Cruciate Ligament-Reconstructed Knee, The American Journal of Sports Medicine 27:pp402-416 Bennett C H, Fu F H, Lattermann C, Ma C B, 1999, Current Trends in Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine, Vol. 27: pp 821-830 Beynnon B, Risberg M.A, Holm I, Steen H, 1999 Sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score ;A prospective study of 120 ACL reconstructed patients with a 2-year follow-up, Journal of Knee Surgery,Traumatology, Arthroscopy 7: pp152-15 Calvisi V, Lupparelli S , Padua R, 2006;Patellar tendon autograft versus hamstring tendon autograft in arthroscopic anterior cruciate ligament reconstruction,: appraisal of the evidence. Journal of orthopaedic traumatology 7:pp103-107 Chantelot C, Debroucker M J, Duquennoy A, Jardin C, Migaud H, Gougeon F, 1999, Reliability of the KT-1000 arthrometer in measuring anterior laxity of
the knee: comparative analysis with Telos of 48 reconstructions of the anterior cruciate ligament and intra- and interobserver reproducibility,
Rev Chir Orthop Reparatrice Appar Mot. 1999 Nov;85(7):698-707 Dunn W R, Lyman S, Lincoln A E, Amoroso P J, Wickiewicz T, Marx R G, 2003, The Effect of Anterior Cruciate Ligament Reconstruction on the Risk of Knee Reinjury, The American Journal of Sports Medicine, Vol. 32, No.8: pp 1906-1914 Ejerhed L, Kartus J Karlsson J, Köhler K, 2001, Evaluation of the reproducibility of the KT-1000 arthrometer, Scandinavian Journal of Medicine & Science in Sports 11 (2), 120–125 Ejerhed L, Kartus J Karlsson J, Köhler K, Sernert N, 2003, Patellar Tendon or Semitendinosus Tendon Autografts for Anterior Cruciate Ligament Reconstruction? A Prospective Randomized Study with a Two Year Follow-Up, The American Journal of Sports Medicine, Vol 31, No.1: pp 19-25 Ejerhed L, Hansson L, Heidvall M, Karlsson J, Kartus J, Laxdal G, 2005 , A prospective randomized comparison of bone-patellartendon-bone and hamstring grafts for anterior cruciate ligament reconstruction, The Journal of Arthroscopy and Related Surgery 21,1:pp 34-42 Feller J A, Webster K E, 2003, A Randomized Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine Vol.31, No. 4:pp 564-573 Freedman, K.B.; D'Amato, M.J.; Nedeff, D.D.; Kaz, A.; Bach Jr., B.R., (Chicago, IL): Arthroscopic Anterior Cruciate Ligament Reconstruction: a meta- analysis comparing patellar tendon and hamstring autografts. Am J Sports Med. 2003 Jan-Feb;31(1):2-11 Goldblatt J, Fitzsimmons S, Balk E, Richmond J, 2005; Reconstruction of the anterior cruciate ligament: Meta-analysis of patellar versus hamstring tendon autograft. The journal of Arthroscopic and Related surgery 7:pp791-803 Harilainen A, Jansson K A, Linko E, Sandelin J, 2003, A prospective randomized study of Patellar versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine, Vol. 31, No. 1:pp 12-18 Harner C, Huber F E, Irrgang, Lephart, 1997,
Intratester and intertester reliability of the KT-1000 arthrometer ...
1997 Jul-Aug;25:pp 479-85. The American Journal of Sports Medicine Herrington L, Wrapson C, Matthews M, Matthews H, Anterior Cruciate Ligament reconstruction, hamstring versus bone–patella tendon–bone grafts: a
systematic literature review of outcome from surgery
Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]. In: The Cochrane Library, Issue 4, 2006. Chichester, UK: John Wiley & Sons, Ltd. Irrgang J, Harner C, Ho H, Fu F, 1998 Use of the International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction 6: pp107-114 Johnson D L, Robbe R 2002 Graft Fixation Alternatives in Anterior Cruciate Ligament Reconstruction, U.P.O.J volume 15 2002: pp 21-28 Laxdal G, Hansson L, Heidvall M, Karlsson J, Kartus J, Ejerhed L, 2005 , A prospective randomized comparison of bone-patellartendon-bone and hamstring grafts for anterior cruciate ligament reconstruction, The Journal of Arthroscopy and Related Surgery 21,1:pp 34-42 Lepage L, Jones A, Moher D, 2001, Use of the CONSORT Statement and Quality of Reports of Randomized Trials: A Comparative Before-and-After Evaluation , JAMA 2001—Vol 285 Lill H, Schonaich M, Voigt C, 2006, Anterior Cruciate Ligament Reconstruction: State of the Art, European Journal of Trauma, Vol 32, no.4: pp 332-339 O’Neill D B,1996, Arthroscopically Assisted Reconstruction of the Anterior Cruciate Ligament. A Prospective Randomized Analysis of Three Techniques, J Bone Joint Surg [Am] 1996; 78-A; pp 803-813
Web reference
Brown D.W, 2006 Anterior Cruciate Ligament (ACL) Reconstruction Technique. Orthopedic associates of Portland. Available from: http://www.orthoassociates.com/acltech.htm
Rosenberg T D MD, 2005 ACL reconstruction with the ACUFEX™ Director Drill Guide and ENDOBUTTON™ CL Fix,ation System, Smith and Nephew ,Inc Available from: www.smith-nephew.com