Three different types of tendon grafts all provide good long-term outcomes in patients undergoing reconstruction of the anterior cruciate ligament (ACL) of the knee, reports a study in the June 5, 2019 issue of The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.
All three approaches to surgical reconstruction of ACL tears improve knee function and related quality of life, according to the new research by Nicholas G. Mohtadi, MD, MSc, FRCSC, and Denise S. Chan, MBT, MSc, of University of Calgary Sport Medicine Centre in Canada. The findings suggest that using a patellar tendon may offer an advantage in reducing the risk of repeat ACL injury in younger, more active patients.
Trial Compares Patellar Tendon, Hamstring Tendon, and 'Double-Bundle' for ACL Repair
The researchers analyzed five-year follow-up data from a study comparing three tendon grafts for ACL reconstruction. The ACL is a major stabilizing ligament of the knee, commonly injured in sports that entail sharp, cutting knee movements such as basketball, football, and skiing.
The original trial included 330 patients, aged 14 to 50 years, with ACL tears. They were randomly assigned to ACL reconstruction using patellar (kneecap) tendon, hamstring tendon, or a "double-bundle" hamstring tendon graft. In a previously published report, the three groups had similar outcomes at two years after surgery.
The new study looked at how well the results held up after five years' follow-up. The analysis included 95 percent of the original patients: 178 men and 137 women. Average age at follow-up was about 34 years.
At five years, the three groups had similarly high ACL quality-of-life scores, with average ratings between 81 and 84 out of 100. The change in scores from two to five years was also similar between groups.
On an objective rating scale, the percentage of patients with "normal or near-normal" knees was somewhat higher in the patellar tendon group (87 percent), compared to those in the hamstring tendon group (82 percent) and in the double-bundle group (75 percent). Scores on a subjective knee rating scale were similar among all three groups.
The patellar tendon group had the lowest overall risk of repeat knee injury: four percent, compared to 15 percent in the hamstring tendon group and 16 percent in the double-bundle group. The risk of tearing the ACL in the opposite knee increased from two to five years' follow-up, with no significant difference between the three groups.
"Anterior cruciate ligament injuries affect quality of life and knee function of thousands of young people annually, typically those in their prime," Dr. Mohtadi and Ms. Chan write. By analyzing five-year data on three tendon options for ACL reconstruction, the study authors provide orthopaedic surgeons with valuable evidence for treatment decision-making.
The results show good five-year outcomes for all three tendon grafts. The main significant difference between techniques is the lower rate of repeat injury to the reconstructed ACL with the patellar tendon graft: about one-fourth the risk when compared to the hamstring-tendon and double-bundle groups. Conversely, kneeling pain was more common with patellar tendon reconstruction.
Traumatic reinjury to the graft remains the most notable problem after ACL reconstruction. "This is even more of an issue for younger patients who are at higher risk [of repeat knee injury]," Dr. Mohtadi and Ms. Chan conclude. The findings of this study prompt the authors to "recommend a patellar tendon reconstruction for higher-risk, younger patients."
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