Femoral press-fit fixation in ACL reconstruction using bone-patellar tendon-bone autograft: results at 15 years follow-up

Abstract

BackgroundIf anterior cruciate ligament (ACL) reconstruction is to be performed, decision regarding graft choice and its fixation remains one of the most controversial. Multiple techniques for ACL reconstruction are available. To avoid disadvantages related to fixation devices, a hardware-free, press-fit ACL reconstruction technique was developed.The aim of this study was to evaluate clinical outcome and osteoarthritis progression in long term after ACL reconstruction with central third patellar-tendon autograft fixed to femur by press-fit technique.MethodsFifty two patients met inclusion/excusion criteria for this study. The patients were assessed preoperatively and at 15 years after surgery with International Knee Documentation Committee Knee Ligament Evaluation Form, Lysholm knee score, Tegner activity scale and radiographs.ResultsGood overall clinical outcomes and self-reported assessments were documented, and remained good at 15 years. The mean Lysholm and Tegner scores improved from 59.7 ± 18.5 and 4.2 ± 1.0 preoperatively to 86.4 ± 5.6 (p = 0.004) and 6.9 ± 1.4 (p = 0.005) respectively at follow-up. The IKDC subjective score improved from 60.1 ± 9.2 to 80.2 ± 8.1 (p = 0.003).According to IKDC objective score, 75% of patients had normal or nearly normal knee joints at follow-up. Grade 0 or 1 results were seen in 85% of patients on laxity testing. Degenerative changes were found in 67% of patients. There was no correlation between arthritic changes and stability of knee and subjective evaluation (p > 0.05).ConclusionsACL reconstruction with patellar tendon autograft fixed to femur with press-fit technique allows to achieve good self-reported assessments and clinical ligament evaluation up to 15 years. Advantages of the bone-patellar-tendon-bone (BPTB) press-fit fixation include unlimited bone-to-bone healing, cost effectiveness, avoidance of disadvantages associated with hardware, and ease for revision surgery. BPTB femoral press-fit fixation technique can be safely applied in clinical practice and enables patients to return to preinjury activities including high-risk sports.

Anterior cruciate ligament injury after more than 20 years: I. Physical activity level and knee function

“…This is probably due to our exclusion criteria regarding no knee problems and hence the knee function of our control group may be better than expected of a true reference group. However, the knee function (Lysholm and KOOS) for ACL‐injured in the present study were also lower than other long‐term studies about 15 years post‐injury for persons treated with ACL reconstruction (Drogset et al., ; Meunier et al., ; Hui et al., ; Widuchowski et al., ; Gerhard et al., ; Stensbirk et al., ) as well as for persons treated with physiotherapy alone (Ageberg et al., ; Kostogiannis et al., ; Meunier et al., ; Neuman et al., ; Streich et al., ). This indicate that knee function may decrease over even longer time perspective.…”

“…The ACL‐injured persons were sports active prior to their injury (median Tegner of 9) and it is of course impossible to speculate on how active they would be today if they had not suffered an injury. Existing long‐term studies on knee‐specific physical activity 15 years or more post‐injury report Tegner scores between 4 to 6 (Maletius & Messner, ; Drogset et al., ; Ageberg et al., ; Kostogiannis et al., ; Meunier et al., ; Neuman et al., ; Mihelic et al., ; Streich et al., ; Widuchowski et al., ; Gerhard et al., ; Stensbirk et al., ), which is in parity or slightly higher compared with our results. Studies on controls show a median level of Tegner activity score 5–6 in the age range of 30–60 years (Andersson‐Molina et al., ; Briggs et al., 2009b), which is in parity compared with our controls.…”

“…Few studies have reported physical activity level and knee function 20 years or more after injury. Long‐term studies of 15 years or more show various results such as good or slightly reduced knee function measured with Lysholm score and Knee injury and Osteoarthritis Outcome Score (KOOS), normal, or reduced knee‐specific activity level on the Tegner activity scale and that knee osteoarthritis (OA) is present in varying degrees both for persons who have been treated with a combination of physiotherapy and surgical reconstruction (Strand et al., ; Drogset et al., ; Meunier et al., ; Hui et al., ; Mihelic et al., ; Streich et al., ; Widuchowski et al., ; Gerhard et al., ; Stensbirk et al., ) as well as for those treated with physiotherapy alone (Ageberg et al., ; Kostogiannis et al., ; Meunier et al., ; Neuman et al., ; Streich et al., ). The boundaries between what is normal or reduced function in many of these scores are however not clearly established, which makes interpretations of outcome cumbersome.…”

“…It is well established that radiological OA is common 15 years after an ACL injury while the long‐term consequences with regard to the actual physical capacity is not well described (Ageberg et al., ; Hui et al., ; Widuchowski et al., ; Gerhard et al., ; Stensbirk et al., ). There is a total lack of studies that directly and comprehensively assess the physical capacity such as jump performance a long time after ACL injury and in relation to degree of OA, while also comparing the performance to that of age‐ and gender‐matched healthy controls.…”

“…Usually, only limb symmetry index (LSI) is reported (and not the absolute values of hop distance), and often also without comparison to norm values or a control group. These studies nevertheless show that 8–35% of ACL‐injured individuals have an unsatisfactory knee function with regard to LSI jump capacity 15–16 years after injury (Ageberg et al., ; Hui et al., ; Widuchowski et al., ; Gerhard et al., ; Stensbirk et al., ). However, demanding knee‐loading activities such as jumps may be influenced by fear of movement/reinjury (Kvist et al., ; Ardern et al., ) and this should therefore also be taken into account.…”