ACL reconstruction with femoral cortical button fixation yielded good 20-year outcomes
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More than 20 years after patients underwent ACL reconstruction with hamstring tendon graft and femoral cortical button fixation, they had a low failure rate, low awareness of the operated knee and good clinical stability.
Frans J.A. Hagemans, MD, Jelle P. van der List, MD, and colleagues assessed graft rupture, reoperation and contralateral injury rates in 94 patients undergoing isolated transtibial primary ACL reconstruction with hamstring tendon graft and femoral cortical button fixation between 1994 and 1996. Researchers measured clinical stability and assessed patient-reported outcome (PRO) measures using IKDC score, Forgotten Joint Score, Tegner activity scale, KOOS score, ACL-Quality of Life and EuroQol-5D 5-Level. Researchers also assessed radiographic osteoarthritis in the ipsilateral and contralateral knee.
Overall, published results showed researchers had a 51% follow-up rate among the patients at a median of 21 years postoperatively and patients experienced graft rupture, contralateral injury (8%) and reoperations (31%) to treat meniscal tears and for hardware removal. Patients with an intact graft reported excellent PROs, including a median Lysholm score of 90, subjective IKDC score of 86 and KOOS-Sports score of 86, according to results. Researchers found patients had low awareness of the operated knee and good quality of life. KT-1000 arthrometer measurements shows a median side-to-side difference of 1 mm. Researchers noted 49% of ipsilateral knees had radiographic OA vs. 10% of contralateral knees, which was associated with meniscectomy at index surgery and decreased PROs at follow-up.
“Hamstring graft techniques with femoral cortical button fixation, such as the one we studied, have been shown to be a reliable technique with good clinical outcomes in the long-term,” Hagemans, of Northwest Clinics in the Netherlands, told Healio Orthopedics. “Hamstring graft techniques with cortical buttons are still widely used and, therefore, it is important that these techniques are being developed further into more less-invasive techniques with similar or even better outcomes. These results also highlight the importance of adequate management of concomitant meniscus injuries, as meniscectomies were associated with a high rate of osteoarthritis.”
Perspective
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This is an important contribution to the ACL literature because there are relatively few outcomes studies with over 20 years follow-up, and nearly all of those utilized patellar tendon grafts, rather than the hamstring grafts used here. The main findings of this study were a relatively low failure rate (8%), good functional outcomes scores, but a high prevalence of radiographic osteoarthritis (49%). So, the high rates of OA are not just a patellar tendon graft phenomenon. This also correlated directly to the presence of a meniscal tear at the index operation, which at the time were all treated with meniscectomy. They utilized a “transtibial isometric” reconstruction which was also common practice in the mid-90s. Their results are comparable to the only other similar study on quadrupled hamstring grafts. Inherent in these longer follow-up studies is the limitation of loss to follow-up (49%), which is significant. Sports medicine is in constant evolution when it comes to new technologies, techniques and understanding. We now recognize the importance of meniscal repairs and anatomic tunnel positioning, and are seeing the return of the quad tendon graft. The ACL reconstructions we do today are different than the ones we did 25 years ago. It will take long-term careful studies like this to help us measure our progress in the future.
Reference:
Salmon LJ, et al. Am J Sports Med. 2018;doi:10.1177/0363546517747497.
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