Summary

Comparable Outcomes for Revision ACL Reconstruction using Bone Patellar Tendon Bone vs. Hamstring Autografts with and without Lateral Extra-articular Tenodesis

Abstract

Background

The rate of revision anterior cruciate ligament reconstruction (ACLR) is rising, yet the most effective surgical approach is yet to be determined. Bone-patellar tendon-bone (BPTB) and hamstring (HT) autografts are commonly used grafts for R-ACLR. Lateral extra-articular tenodesis (LEAT) can augment ACL reconstruction, although its implications with different graft types remain unclear.

Purpose

This study compares R-ACLR outcomes using BPTB vs. HT autografts with and without lateral extra-articular tenodesis. We compared return to play (RTP) rate, RTP timing, the incidence of subsequent ACL injury, and patient-reported outcomes at 2 years.

Design: Cohort study; Level 3 evidence

Methods

A prospective cohort study of 265 consecutive patients who underwent revision ACLR using an ipsilateral knee, BPTB (n = 159) or HT (n = 106) autograft at a single centre between 2014 and 2018. Patients underwent BPTB reconstruction if they had previously undergone HT reconstruction and vice-versa. Patients were excluded if they sustained a multi-ligament knee injury or the graft was harvested from the contralateral leg. A subgroup analysis was performed on those who received LEAT and those who did not. Data on RTP, ipsilateral ACL injuries, contralateral ACL injuries and patient-reported outcome measures (IKDC, Marx) were analysed at a minimum of 2 years follow-up.

Results

The mean age was 25.4 +/- 6.3 years and 85.4% of patients were male. The RTP rate was comparable between the BPTB and HT groups (65.2% vs. 62.8%, p = .400). The average time to RTP was 13.3 +/- 5.7 months for the BPTB group and 12.4 +/- 6.1 months for the HT group. There was no statistically significant difference in the rate of graft re-injury between the BPTB and HT cohorts (2.9% vs. 3.2%: p = .582). Graft re-injury rates for HT autografts with and without LEAT were 1.4% vs. 6.3%, p = .163, respectively. There was also no difference between BPTB and BPTB + LEAT graft re-injury rates (2.8% vs. 1.9%, p = .720). There was an overall reduction in Marx score for all patient groups. There was no statistically significant difference in IKDC score between the BPTB and HT cohorts (83.3 +/- 11.7 vs. 83.6 +/- 13.9, p = .885). There was also no difference compared to the LEAT group despite these patients being significantly younger and having a lower incidence of chondral injuries.

Conclusions

This study demonstrated that using BPTB and HT autografts for revision ACLR resulted in a similar RTP rate and patient-reported outcomes. Interestingly, although patients in the LEAT group were younger and had a lower incidence of chondral injuries, this did not translate into improved outcomes. Notably, all patients' activity levels were significantly reduced after revision ACLR regardless of graft type used.