Long‐term outcomes of anterior cruciate ligament reconstruction surgery: 2020 OREF clinical research award paper

Abstract

ACL injuries place the knee at risk for post-traumatic osteoarthritis (PTOA) despite surgical anterior cruciate ligament (ACL) reconstruction. One parameter thought to affect PTOA risk is the initial graft tension. This randomized controlled trial (RCT) was designed to compare outcomes between two graft tensioning protocols that bracket the range commonly used. At 7 years postsurgery, we determined that most outcomes between the two tension groups were not significantly different, that they were inferior to an uninjured matched control group, and that PTOA was progressing in both groups relative to controls. The trial database was also leveraged to gain insight into mechanisms of PTOA following ACL injury. We determined that the inflammatory response at the time of injury undermines one of the joint's lubricating mechanisms.We learned that patients continue to protect their surgical knee 5 years postinjury compared to controls during a jump-pivot activity. We also established that presurgical knee function and mental health were correlated with symptomatic PTOA at 7 years, that there were specific anatomical factors associated with poor outcomes, and that there were no changes in outcomes due to tunnel widening in patients receiving hamstring tendon autografts. We also validated a magnetic resonance imaging technique to noninvasively assess graft strength. In conclusion, the RCT determined that initial graft tensioning does not have a major influence on 7-year outcomes. Therefore, surgeons can reconstruct the ACL using a graft tensioning protocol that is within the window of the two graft tensioning techniques evaluated in this RCT.

Effects of Initial Graft Tension and Patient Sex on Knee Osteoarthritis Outcomes After ACL Reconstruction: A Randomized Controlled Clinical Trial With 10- to 12-Year Follow-up

“…Collectively, these findings suggest that ACLR failed to mitigate PTOA risk regardless of initial graft tension, which is consistent with the existing literature. 4,18,19 Interestingly, the low-tension group alone scored worse than the control group for the KOOS Symptoms and OARSI difference score outcomes, suggesting that a low initial graft tension may predispose patients to arthrosis that is not reflected by the IKDC examination, KOOS (Pain, ADL, Sport, and QOL subscales), or WORMS difference score outcomes. However, among female and male patients, the low-tension group tended to have worse IKDC examination scores relative to the control group (Appendix Tables A9 and A10, available online), suggesting that this score may have an emerging sensitivity to osteoarthritic changes within this group.…”

“…21 However, clinical studies demonstrate that PTOA often progresses despite surgical intervention. 14,19,21,33 The reason for this progression remains unclear, although the initial graft tension applied at the time of fixation has been implicated as an important contributing factor. 19 The American Journal of Sports Medicine 2022;50 (13):3510-3521 DOI: 10.1177/03635465221124917 Ó 2022 The Author(s)…”

“…21 However, clinical studies demonstrate that PTOA often progresses despite surgical intervention. 14,19,21,33 The reason for this progression remains unclear, although the initial graft tension applied at the time of fixation has been implicated as an important contributing factor. 19…”

“…14,19,21,33 The reason for this progression remains unclear, although the initial graft tension applied at the time of fixation has been implicated as an important contributing factor. 19…”

Development and application of the online initial graft tension measurement system for anterior cruciate ligament reconstruction

“…Sports participation declined from 82% postoperatively to 57% in the long-term follow-up. Postoperative knee osteoarthritis contributes to postoperative joint pain, dysfunction, and drastically reduced quality of life [3][4][5][6].…”