Femoral-tibial fixation affects risk of revision and reoperation after anterior cruciate ligament reconstruction using hamstring autograft

Spragg, Lindsey; Prentice, Heather A.; Morris, Andrew J.; Funahashi, Tadashi T.; Maletis, Gregory B.; Csintalan, Rick P.

doi:10.1007/s00167-019-05431-4

Cited by 14 publications

(19 citation statements)

References 42 publications

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“…A second issue is related to fixation methods, as a higher revision risk was reported using suspensory fixation, which is typical of the AM portal technique, as opposed to the cross-pin and interference screws usually used in the TT drilling approach. 48 Third, a recent single-surgeon case series of 1480 patients by Clatworthy et al 10 identified a higher risk of failure when the AM portal technique was used compared with the TT approach. However, the different drilling techniques coincided with different graft placement: a “central” footprint position was in fact achieved with the AM portal, while an “eccentric” position within the native footprint, close to the insertion of the ACL direct fibers, was obtained with the TT technique.…”

Section: Discussionmentioning

confidence: 99%

Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression

Cuzzolin

Previtali

Delcogliano

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: Anterior cruciate ligament (ACL) reconstruction can be performed with different techniques for independent and transtibial (TT) drilling of femoral tunnels, but there is still no consensus on which approach leads to the best outcome. Purpose: To assess whether the independent or TT drilling approach for ACL reconstruction leads to the best functional outcomes. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic literature search was conducted on July 1, 2020, using the PubMed, Web of Science, Cochrane Library, and Scopus databases. The influence of different femoral drilling techniques was analyzed through a meta-analysis in terms of patient-reported outcome measure scores, risk of complications, range of motion limitations, graft failure, and differential laxity. Subanalyses were performed to compare the different independent drilling techniques considered. Linear metaregression was performed to evaluate if the year of study publication influenced the results. The risk of bias and quality of evidence were assessed following the Cochrane guidelines. Results: A total of 22 randomized controlled trials including 1658 patients were included in the meta-analysis. Both International Knee Documentation Committee (IKDC) subjective score and Lysholm score were higher with the independent drilling approach (mean difference [MD], 1.24 [ P = .02] and 0.55 [ P = .005], respectively). No difference was documented in terms of the risk of reinjury, but independent drilling led to reduced KT-1000 arthrometer–assessed anterior tibial translation (MD, 0.23; P = .01) and a higher probability of a negative postoperative pivot-shift test finding (risk ratio, 1.13; P = .04). There were no significant differences in IKDC objective or Tegner scores. A P value of .07 was found for the association between the year of the study and IKDC objective scores. Conclusion: Independent femoral tunnel drilling provided better results than the TT approach, although the difference was not clinically significant. No difference was observed in the risk of reinjury. Increasingly better results were seen among surgical procedures performed in more recent years. Among the independent drilling options, the anteromedial portal technique seemed to provide the most favorable outcomes. The lack of clinically significant differences and the promising outcomes reported with new modified TT techniques suggest the importance of correct placement, rather than the tunnel drilling approach, to optimize the results of ACL reconstruction.

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Section: Discussionmentioning

confidence: 99%

Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression

Cuzzolin

Previtali

Delcogliano

et al. 2021

Orthopaedic Journal of Sports Medicine

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“…51 Given this finding, we limited the current study cohort to patients aged 25 years or younger in order to evaluate those patients at the highest risk of revision. Previous studies have also reported a lower revision risk with both crosspin femoral fixation 44 and transtibial drilling. 9,39,47 The allograft ACLR group had higher proportions of these protective factors; however, after adjustment for femoral fixation and tunnel drilling technique in our regression model, we still found a higher risk of revision for the allograft ACLR group.…”

Section: Discussionmentioning

confidence: 78%

Revision Risk of Soft Tissue Allograft Versus Hybrid Graft After Anterior Cruciate Ligament Reconstruction

et al. 2020

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Background: When a harvested hamstring autograft is deemed by the surgeon to be of inadequate diameter, the options include using the small graft, using another autograft from a different site, augmenting with an allograft (hybrid graft), using a different configuration of the graft (eg, 5- or 6-stranded), or abandoning the autograft and using allograft alone. A small graft diameter is associated with a higher revision risk, and using another autograft site includes added harvest-site morbidity; therefore, use of a hybrid graft or an allograft alone may be appealing alternative options. Revision risk for hybrid graft compared with soft tissue allograft is not known. Purpose: To evaluate the risk for aseptic revision surgery after primary anterior cruciate ligament reconstruction (ACLR) using a soft tissue allograft compared with ACLR using a hybrid graft in patients 25 years and younger. Study Design: Cohort study; Level of evidence, 3. Methods: Data from a health care system’s ACLR registry were used to identify primary isolated unilateral ACLRs between 2009 and 2016 using either a hybrid graft (hamstring autograft with soft tissue allograft) or a soft tissue allograft alone. Multivariable Cox proportional hazards regression was used to evaluate risk for aseptic revision after ACLR according to graft used after adjustment for age, allograft processing, tunnel drilling technique, and region where the primary ACLR was performed. Results: The cohort included 2080 ACLR procedures; a hybrid graft was used for 479 (23.0%) ACLRs. Median follow-up time was 3.4 years (interquartile range, 1.8-5.1 years). The crude 2-year aseptic revision probability was 5.4% (95% CI, 4.3%-6.7%) for soft tissue allograft ACLR and 3.8% (95% CI, 2.3%-6.4%) for hybrid graft ACLR. After adjustment for covariates, soft tissue allograft ACLR had a higher risk of aseptic revision during follow-up compared with hybrid graft ACLR (hazard ratio, 2.00; 95% CI, 1.21-3.31; P = .007). Conclusion: Soft tissue allografts had a 2-fold higher risk of aseptic revision compared with hybrid graft after ACLR. Future studies evaluating the indications for using hybrid grafts and the optimal hybrid graft diameter is needed.

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“…31 However, the authors did not find an association between the type of tibial fixation and revision risk. In the United States, a study performed by Spragg et al 40 involving 6593 patients recorded in the Kaiser Permanente ACL Registry found a higher reoperation rate with suspensory tibial devices, but no difference in revision risk when compared with interference tibial devices. 40 Surgical practice in New Zealand differs, as nearly all hamstring tendon autografts are fixed with a suspensory device on the femoral side.…”

Section: Discussionmentioning

confidence: 99%

“…In the United States, a study performed by Spragg et al 40 involving 6593 patients recorded in the Kaiser Permanente ACL Registry found a higher reoperation rate with suspensory tibial devices, but no difference in revision risk when compared with interference tibial devices. 40 Surgical practice in New Zealand differs, as nearly all hamstring tendon autografts are fixed with a suspensory device on the femoral side. In contrast to these studies, we found a higher revision rate with interference tibial devices.…”

Section: Discussionmentioning

confidence: 99%

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Suspensory Versus Interference Tibial Fixation of Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry

Rahardja

Love²,

Clatworthy

et al. 2022

Am J Sports Med

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Background: The hamstring tendon is frequently used to reconstruct the anterior cruciate ligament (ACL), but there is a lack of consensus on the optimal method of fixation. Registry studies have shown that the type of femoral fixation device can influence the risk of revision ACL reconstruction (ACLR), but it is unclear whether the type of tibial fixation has an effect. In New Zealand, over 95% of hamstring tendon grafts are fixed with an adjustable loop suspensory device on the femoral side, with variable usage between suspensory and interference devices, with or without a sheath, on the tibial side. Purpose: To investigate the association between the type of tibial fixation device and the risk of revision ACLR. Study Design: Cohort Study; Level of evidence, 2. Methods: Prospective data recorded in the New Zealand ACL Registry were analyzed. Only primary ACLRs performed with a hamstring tendon autograft fixed with a suspensory device on the femoral side were included. A Cox regression survival analysis with adjustment for patient factors was performed to analyze the effects of the type of tibial fixation device, the number of graft strands, and graft diameter on the risk of revision. Results: A total of 6145 primary ACLRs performed between 2014 and 2019 were analyzed. A total of 59.6% of hamstring tendon autografts were fixed with a suspensory device on the tibial side (n = 3662), 17.6% with an interference screw with a sheath (n = 1079), and 22.8% with an interference screw without a sheath (n = 1404). When compared with suspensory devices, a higher revision risk was observed when using an interference screw with a sheath (adjusted hazard ratio [HR], 2.05; P = .009) and without a sheath (adjusted HR, 1.81; P = .044). The number of graft strands and a graft diameter of ≥8 mm were associated with the rate of revision on the univariate analysis; however, after adjusting for confounding variables on the multivariate analysis, they did not significantly influence the risk of revision. Conclusion: In this study of hamstring tendon autografts fixed with an adjustable loop suspensory device on the femoral side during primary ACLR, the use of an interference screw, with or without a sheath, on the tibial side resulted in a higher revision rate when compared with a suspensory device.

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Femoral-tibial fixation affects risk of revision and reoperation after anterior cruciate ligament reconstruction using hamstring autograft

Cited by 14 publications

References 42 publications

Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression

Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression

Revision Risk of Soft Tissue Allograft Versus Hybrid Graft After Anterior Cruciate Ligament Reconstruction

Suspensory Versus Interference Tibial Fixation of Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry

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