Summary

No Difference in Complication Rates or Patient-Reported Outcomes Between All Soft Tissue Quadriceps Tendon and Bone-Patella Tendon-Bone or Hamstring Autograft for Anterior Cruciate Ligament Reconstruction.

Abstract

Introduction

Anterior cruciate ligament reconstruction (ACLR) can be performed with a number of different autografts including all soft tissue quadriceps autograft. (S-QT). S-QT has several advantages including decreased donor site morbidity, reduced anterior knee pain and comparable revision rates compared to other autografts. The primary aim of this review was to assess all complications of QT in adult population.

Methodology

A systematic review of the literature was conducted on in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. Clinical studies reporting on isloated primary ACLR using S-QT in the last 20 years were included and appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool.

Results

Eighteen studies were eligible, 3 radomised control trials (RCT), 11 comparative studies and 4 case series giving a total of 1145 cases of S-QT ACLR, 57% were men. The mean age was 26.8 ± 6.6 years (16-50) and. The mean follow-up was 23.6 months (6-65 months). Eight comparative studies reported the use of Hamstring (HT) graft and 5 studies reported the use of bone patellar tendon bone (BPTB) graft with 498 and 174 patients, respectively. Thirteen studies reported on post operative patient reported outcome measure scores (PROMs). International Knee Documentation Committee (IKDC) score was the most reported score in 11 studies followed by Lysholm score in 9 studies. All PROMs scores were comparable to HT and BPTB except one study found significant difference in Lysholm score in favour of BPTB (82 vs 90, p=0.055). Nine studies reported on knee laxity post operatively with various methods of clinical and instrumented assessment with no significant differences observed compared to BPTB.

Complications of S-QT were reported in 14 studies, with overall complication rate of 8.2 % (89 patients). Graft failure was the most common complication n= 39 (3.5%), followed by Cyclops lesion n=17 (1.5%) and Arthrofibrosis n=14 (1.3%). Infection was not a common complication with three patients from 2 studies, n= 3 (0.3%). Hardware prominence was the least reported complications with two patients who required hardware removal in one study n= 2 (0.2%). Re-operation for any reason was performed in 53 patients (4.7%). Anterior Knee/Kneeling pain was reported in 62 patients (5.6%) from 4 studies and graft site numbness in n= 4 (0.4%) from two studies. One study showed less donor site morbidity compared to BPTB and HT. Six studies reported no local complications and no graft site morbidity with S-QT. One study reported on less post operative pain and analgesia required with S-QT compared to HT in the immediate post-operative period (72 hours). Re-operation was perfromed in 89 patients (8.1%) with Cyclops lesion the most common cause for re-operation n=26 (2.3%)

Conclusion

No significant difference in functional outcome scores, knee stability and ROM between soft tissue QT, HT and BPTB. QT demonstrated similar quadriceps recovery and return to sport at 9-12 months. Similar graft failure and reoperation rates at 2 years post-op with low infection <0.5% Less analgesia consumption and better HT/QT ratio compared to HT and less anterior knee/kneeling pain at harvest site compared to BPTB. Further level I studies are recommended.