ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN ≤21 YEAR OLDS: PATELLAR VERSUS HAMSTRING TENDON AUTOGRAFTS

摘要

Background: Bone-patellar tendon-bone (BTB) and hamstring tendon (HS) are commonly used grafts for anterior cruciate ligament reconstruction (ACLR). The optimal graft choice for ACLR remains unclear. We evaluated clinical and self-reported outcomes of patients who underwent ACLR with use of a BTB autograft or double-bundle HS autograft/allograft-augmented HS autograft (HS hybrid). Hypothesis/Purpose: No significant differences in outcomes exist between graft choices. Methods: Retrospective review of prospectively collected data from patients aged ≤ 21 years who underwent primary ACLR with BTB or HS autograft/hybrid by one fellowship-trained orthopaedic surgeon and a minimum of 6 months follow-up. Demographics, injury characteristics, concomitant injuries, surgical and radiographic parameters were recorded. Clinical and patient self-reported outcomes (Tegner-Lysholm, pediIKDC, KOOSChild) were compared at 6-months, 1-year and latest follow-up. Results: A total of 109 subjects were included; 59 had a HS graft (55 HS autograft, 4 HS hybrid) and 50 a BTB autograft. Patients were between 13 and 21 years old at ACLR and had a follow-up of 1.5 ±1 year. Baseline comparison of demographic, injury and surgical parameters is presented in Table1.1. Graft rupture occurred in 10 patients (9.2%; 9 males and 1 female) at an average of 2 years after initial ACLR; 8 graft ruptures occurred in the HS group (13.6%, none in HS hybrids) and 2 in the BTB group (4%) (p=0.105). Parameters increasing the likelihood of a re-tear were older age at ACLR (HR: 2.348, p&0.005), a &1-year delay to surgery (HR: 4.105, p=0.048) and a concomitant chondral injury (HR: 5.476, p=0.038) (Cox proportional hazards model, Table1.2). Arthrofibrosis developed in 4 BTB patients (8%) at an average of 6 months after initial ACLR, but not in HS patients (p= 0.041 ). At most recent follow-up, patellofemoral pain was present in 15 (28%) HS and 5 (10%) BTB patients (p= 0.027 ) and a contralateral ACL tear had occurred in 4 patients (3.7%). No differences were seen between graft groups for knee range of motion, Lachman testing, leg raise, ligament stability and subjective scores - Tegner-Lysholm, pediIKDC, KOOSChild (p&0.05 for each comparison at 6-months, 1-year and most recent follow-up). Conclusion: In patients &21 years undergoing ACLR, BTB autograft lead to fewer graft ruptures, however, was associated with a higher rate of arthrofibrosis. Older age at surgery, a delay to surgery and chondral injuries increased the likelihood of re-tear. However, failure rates were low, and we observed no differences between graft types in terms of laxity and patient self-reported outcomes. Tables/Figures: Table 1. Demographics HS, N=59 BTB, N=50 P-Value Gender, Female 23 (39%) 22 (44%) 0.697 Age at Surgery, years 16.7 ± 1.61 16.5 ± 1.33, 0.382 BMI 25.2 ± 4.0 26.9 ± 5.3 0.146 Follow-up time, years 1.84 ± 1.19, range 0.5-4.8 1.11 ± 0.70, range 0.5-4.21 &0.005 Injury Parameters Time Injury to Surgery, years 0.41 ± 0.34, range 0.07-1.65 0.52 ± 0.52, range 0.09-2.52 0.477 Laterality, Right 33 (56%) 25 (50%) 0.568 Meniscus tear, yes 35 (59%) 40 (80%) 0.024 Chondral Injury, yes 22 (37%) 16 (32%) 0.687 Surgical Parameters Graft Size, mm 8.6 ± 0.62, range 8-10 10 ± 0.1, range 9.5-10 &0.005 Fem. Tunnel Diameter, mm 8.6 ± 0.6 10 ± 0 &0.005 Femoral Tunnel Depth, mm 29.9 ± 4.2 27.8 ± 1.2 0.014 Tibial Guide Angle, ° 55.2 ± 1.0, range 55-60 58.1 ± 2.7, range 50-65 &0.005 Tibial Tunnel Diameter, mm 8.6 ± 0.6 10 ± 0.1 &0.005 Meniscus surgery 0.050 None 25 (42.4%) 10 (20%) Meniscectomy 12 (20.3%) 15 (30%) Repair 22 (37.3%) 25 (50%) Chondroplasty, yes 6 (10%) 9 (18%) 0.274 Notchplasty, yes 7 (12%) 7 (14%) 0.782 Radiographic parameters Femoral Tunnel Angle, ° 34.6 ± 6.3 31.7 ± 8.3 0.064 Tibial Tunnel Angle, ° 64.8 ± 7.3 68.4 ± 7.3 0.011 PDFA, ° 87.3 ± 3.7 86.9 ± 4.2 0.582 Data are presented as Mean ± SD or N (%) Differences in demographic, injury, surgery and radiographic parameters between the two graft groups were compared using t-tests or Wilcoxon rank-sum tests for con.tinuous variables and chi-square or Fisher’s exact tests for categorical variables Table 2. Factors associated with time to graft rupture Demographics Hazard Ratio 95% CI P-value Gender, Male 5.888 0.728, 47.63 0.097 Age at Surgery, years 2.348 1.439, 3.831 &0.005 BMI 0.986 0.844, 1.153 0.863 Injury Parameters Time Injury to Surgery, ref within 0.5 years & 1 year 4.105 1.010,16.69 0.048 Meniscus tear, yes 4.029 0.499, 32.55 0.191 Chondral Injury, yes 5.476 1.102, 27.22 0.038 Surgical Parameters Graft type, reference HS 0.902 0.176, 4.629 0.902 Graft Size, mm 1.285 0.549, 3.007 0.563 Fem. Tunnel Diameter, mm 1.290 0.550, 3.022 0.558 Femoral Tunnel Depth, mm 0.975 0.824, 1.155 0.771 Tibial Guide Angle, ° 1.176 0.791, 1.748 0.422 Tibial Tunnel Diameter, mm 1.101 0.497, 2.442 0.812 Meniscus surgery, reference none Meniscectomy 5.366 0.595, 48.41 0.1