Autograft choice influences ACL reconstruction rates of young athletes
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Young athletes have a higher chance of subsequent ACL graft revision years after initial reconstruction if opting for a hamstring tendon autograft rather than a bone-patella-bone autograft, according to findings from a recently published study.
“The goal of this study was to determine the incidence of both ACL graft revisions and contralateral ACL tears resulting in subsequent [ACL reconstruction]ACLR,” researchers wrote. “The intention of this analysis was to provide assistance to a physician in the office discussing autograft choice with a patient before ACLR.”
In this multiyear, multicenter consortium, 770 athletes between the ages of 14 and 22 years who were injured while participating in sports were enrolled to complete a questionnaire of baseline demographics, injury descriptors, sports participation levels, comorbidities, surgical knee history and outcome measures. Patients underwent either a hamstring tendon autograft (36%) or a bone-patella-bone (BTB) autograft (64%). A 6-year follow-up showed 19.7% of patients underwent subsequent surgery.
Surgeon influence was the biggest factor in graft choice, and patients’ competition levels and age were secondary factors. The study showed 9.2% of patients underwent additional ipsilateral revision (7.1% BTB; 13% hamstring) and 11.2% of patients had a later contralateral ACL tear resulting in primary ACLR (12.6% BTB; 8.6% hamstring). These results complemented previous study results that also reported higher failure rates in patients who underwent reconstruction with hamstring autografts compared to BTB autografts.
In conclusion, the researchers wrote, “There was a relatively high incidence of subsequent ACLR in both the ipsilateral and contralateral knees in this young athletic cohort at 6 years. Multivariable analysis demonstrated that the incidence of subsequent ACL graft revision at 6 years after index surgery was 2.1-times higher with a hamstring autograft compared with a BTB autograft.” —Kate Burba
Disclosures: Spindler reports he received royalties from nPhase; consulting fees from the National Football League, Cytori, Mitek and Flexion Therapeutics; research funding from Smith & Nephew Endoscopy and DonJoy Orthopedics; and hospitality payments from DePuy and Biosense Webster. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Shital N. Parikh, MD
In a well-designed prospective study, the authors determined the incidence of subsequent ACL reconstruction in 770 young athletes followed for 6 years after primary ACL reconstruction to be 9.2% in the ipsilateral knee, 11.2% in the contralateral normal knee and 19.7% for either knee. The predictors of revision ACL reconstruction in the ipsilateral knee were age, high-grade preoperative knee laxity and autograft type, with the failure rate being double with hamstring autograft compared to bone-patellar tendon-bone autograft.
The strengths of the study are prospective enrollment, unique cohort and high follow-up rate. The study also provides a useful nomogram that can be used to predict the risk of ACL graft failure in ipsilateral knee, with the only modifiable risk factor being the type of autograft, which is largely surgeon’s choice.
The study would have been more informative if the timeline for ACL graft failure, mechanism of failure and details of surgical technique for primary ACL reconstruction (ACLR; femoral tunnel drilling and fixation methods) were analyzed. For example, if the majority of ACL failures were in first postoperative year, then preventive efforts could be instituted during this timeframe. The other drawback of the study is the lack of outcome measures at 6 years besides the incidence of subsequent ACLR in either knee. It is possible that patients with BTB autograft, were actually limited or worse on a functional scale which may have led to these patients being less active and thus had lower ACL retear rate compared to hamstring autograft. Other factors such as ease of rehabilitation, cosmesis, open physis and anterior knee pain are also important considerations that would favor hamstring autograft but were not analyzed in this study.
This study highlights the high ACL retear rate in the ipsilateral and contralateral knee in this young athletic cohort and raises important questions. Should an alternate autograft (quadriceps tendon) be considered in this subset of patients? Should a lateral extra-articular tenodesis procedure be considered in addition to ACLR in patients with high-grade laxity? Would further delay in return to sports help to decrease retear rates? Future studies should explore ways to help decrease the rate of ACL retears in this cohort. For the time being, surgeons should strongly consider BTB over hamstring autograft for ACLR in young athletes with closed physis.
Cincinnati Children’s Hospital Medical Center
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