2023 ISAKOS Biennial Congress Paper
Knee Extensor Mechanism Complications Following Autograft Harvest In ACL Reconstruction: A Systematic Review and Meta-Analysis
Nicholas A. Trasolini, MD, Winston Salem, NC UNITED STATES
Rae Lan, BS, New York, NY UNITED STATES
Ioanna K Bolia, MD, MSc, PhD, Los Angeles, CA UNITED STATES
William Hill, MD, Los Angeles, California UNITED STATES
Ashley Ann Thompson, BS, Los Angeles, California UNITED STATES
Cory K. Mayfield, MD, Los Angeles, CA UNITED STATES
Derrick Michael Knapik, MD, Chesterfield, Missouri UNITED STATES
Brian J. Cole, MD, MBA, Chicago, IL UNITED STATES
Alexander E. Weber, MD, Los Angeles, CA UNITED STATES
USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, UNITED STATES
FDA Status Not Applicable
Summary
Based on current literature, the proportion of extensor mechanism complications after ACL reconstruction using either bone-patellar-tendon-bone or quadriceps tendon autograft is low, indicating that extensor mechanism harvest remains a safe option.
Abstract
Background
ACL reconstruction (ACLR) is a widely studied operation in the literature with the goal of optimizing techniques and patient outcomes. Graft choice is an important consideration in ACLR, as previous studies have reported donor site morbidity in the form of kneeling pain and anterior knee pain with bone-patellar-tendon-bone (BTB) or quadriceps tendon (QT) autografts. A less frequent yet substantial source of morbidity using extensor mechanism grafts is the potential for extensor mechanism disruption in the form of post-operative patella fracture or donor site tendon rupture. Existing systematic reviews have sought to characterize the relative donor site morbidity of BTB and QT grafts, but these studies have focused on donor site symptoms without reporting pooled proportions of patella fractures and donor tendon ruptures across the body of literature.
Purpose
To estimate the proportion of patella fractures, patellar tendon ruptures, and quadriceps tendon ruptures associated with bone-patellar-tendon-bone (BTB) or quadriceps tendon (QT) autograft harvest during anterior cruciate ligament reconstruction (ACLR) using published data.
Methods
A meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Peer-reviewed articles in English reporting on extensor mechanism complications associated with graft harvest in patients undergoing ACLR were included. Pooled proportions of patellar fractures, patellar tendon ruptures, and quadriceps tendon ruptures were calculated for each graft type (BTB, QT) a using random effects model.
Results
Twenty-eight studies were analyzed. Nineteen studies (n = 8424) reported patellar fracture data for BTB autograft, and eight studies (n = 766) reported patellar fracture data for QT autograft. The pooled proportion of patellar fractures was 0.57% (95% CI:0.34%-0.91%) for BTB and 2.03% (95%CI:0.78%-3.89%) for QT. Ten studies (n = 10,890) reported patellar tendon rupture after BTB autograft, while three studies (n = 376) reported quadriceps tendon tears following QT. The proportion of patellar tendon ruptures after BTB harvest was 0.22% (95%CI:0.14%-0.33%) and the proportion of quadriceps tendon ruptures after QT harvest was 0.52% (95%CI: 0.06% -1.91%). Based on the available literature, in 1000 BTB ACLR, one could expect 5.7 patella fractures and 2.2 patellar tendon ruptures; in 1000 QT ACLR, one could expect 20.3 patella fractures and 5.2 quadriceps tendon ruptures. The majority (16/28, 57.1%) of included studies were of level of evidence IV.
Conclusion
Based on current literature, the proportion of extensor mechanism complications after ACL reconstruction using either BTP or QT autograft is low, indicating that extensor mechanism harvest remains a safe option. Surgeons can use these data to better inform their patients on the relative morbidity of autograft options in ACL reconstruction.