Clinical and Radiographic Outcomes of Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Graft and Femoral Cortical Button Fixation at Minimum 20-Year Follow-up

Abstract

Background: The short-term outcomes of anterior cruciate ligament (ACL) reconstruction with bone–patellar tendon–bone or hamstring tendon (HT) graft are excellent with good clinical stability and patient-reported outcomes. Although some studies have reported the long-term outcomes of bone–patellar tendon–bone graft ACL reconstruction, few have reported the outcomes of HT graft ACL reconstruction. Purpose: To assess clinical and radiographic outcomes of HT graft ACL reconstruction with femoral cortical button fixation at a minimum 20-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: A prospective study was performed in which all patients undergoing isolated transtibial primary ACL reconstruction between 1994 and 1996 with HT graft and femoral cortical button fixation were assessed clinically and radiographically. Follow-up was obtained in 48 of 94 patients (51%). Median (interquartile range) age at operation was 31 years (26-39 years); median follow-up was 21 years (20-22 years); 65% were male; and 48% had meniscal injury at surgery and underwent partial meniscectomy. Graft rupture, reoperation, and contralateral injury rates were assessed; clinical stability was measured using the KT-1000 arthrometer; patient-reported outcomes were assessed (International Knee Documentation Committee [IKDC], Lysholm, Forgotten Joint Score, Tegner activity, Knee injury and Osteoarthritis Outcome Score [KOOS], Anterior Cruciate Ligament Quality of Life [ACL-QOL], EuroQol 5-Dimension 5-Level [EQ-5D-5L]); and radiographic osteoarthritis (defined as Kellgren-Lawrence grade ≥2) was assessed for the ipsilateral and the contralateral knee. Results: Graft rupture occurred in 4 patients (8%), contralateral injury in 4 patients (8%), and reoperation in 15 patients (31%), which consisted mainly of meniscal tears or hardware removal. In patients with an intact graft, excellent patient-reported outcome measures (PROMs) were noted, with a median Lysholm of 90 (78-100), subjective IKDC of 86 (72-95), and KOOS–Sports of 86 (58-100). There was low awareness of the operated knee (Forgotten Joint Score, 81 [60-96]) and good quality of life (ACL-QOL, 85 [75-94]; EQ-5D-5L, 0.87 [0.83-1.00]). Median side-to-side difference, as measured with the KT-1000 arthrometer, was 1 mm (-1 to 3 mm). Radiographic osteoarthritis was evident in 49% of ipsilateral and 10% of contralateral knees and was associated with meniscectomy at index surgery and decreased PROMs at follow-up. Conclusion: Long-term outcomes of transtibial HT graft ACL reconstruction with femoral cortical button fixation are generally good with a low failure rate, low awareness of the operated knee, and good clinical stability. Radiographic osteoarthritis was evident in approximately half of the patients at 20-year follow-up and was associated with meniscectomy at index surgery and decreased PROMs at follow-up.

An Anterior Cruciate Ligament Rupture Increases Levels of Urine N-terminal Cross-linked Telopeptide of Type I Collagen, Urine C-terminal Cross-linked Telopeptide of Type II Collagen, Serum Aggrecan ARGS Neoepitope, and Serum Tumor Necrosis Factor–α

“…Previous studies have shown that signs of OA are present in 10% to 90% of patients at 10 to 20 years after an ACL injury. 11 , 18 , 21 The identification of patients with early-onset OA is crucial to prevent or minimize further harm to the knee joint, and this could aid in developing treatment options for early OA. However, before clinical signs become apparent, OA has already been initiated.…”

Clinical Outcomes and Osteoarthritis at Very Long-term Follow-up After ACL Reconstruction: A Systematic Review and Meta-analysis

“…Two other studies were prospective case-control studies comparing different autografts 31 or comparing nonoperative versus operative treatment 33 ; in the latter case, patients treated nonoperatively were not included in the analysis. A further 6 studies were prospective case series, 17 , 19 , 26 – 28 , 37 and 5 studies were retrospective case series. 9 , 10 , 20 , 23 , 36 The 74 patients who received hamstring tendon grafts in the comparative study by Thompson et al 31 were excluded from the analysis because they were already accounted for in another study from the same authors evaluating 200 ACLRs with hamstring tendons 27 ; however, data from Thompson et al 31 were used if not available in the complete series.…”

“…OA was evaluated in 14 studies ‡‡ including 1330 patients: The radiographic IKDC score was used in 7 studies 9 , 10 , 23 , 27 , 28 , 31 , 36 ; the Kellgren-Lawrence classification, in 4 studies 17 , 26 , 33 , 37 ; and the Ahlbäck classification, in 3 studies 6 , 11 , 29 ( Table 4 ).…”

Editorial Commentary: Meniscus Tears Seen at the Time of Anterior Cruciate Ligament Reconstruction Are Overtreated

“…We know that the long-term outcomes for ACL reconstruction patients are greatly influenced by the status of the meniscus and that patients with partial meniscectomy have lower subjective scores and greater rate of osteoarthritis. [8][9][10][11][12] Given this information, some surgeons continue to repair MMTs that are degenerative in nature and extend into the avascular zone. [13][14][15][16][17] Shelbourne and Carr 16 evaluated patients who had unstable bucket-handle MMTs that were either repaired or removed at ACL reconstruction.…”