Anterior cruciate ligament reconstruction with hamstring tendons and accelerated rehabilitation: a 10-year prospective study on clinical results, knee osteoarthritis and its predictors

Prospectieve studie naar de lange termijn resultaten na quadruple hamstring-voorste kruisband reconstructies. Uitgebreide analyse middels subjectieve, objectieve en radiologische parameters bij 100 patiënten. Accepted for publication in KSSTA Sept 24, 2012. De studie is gepresenteerd op ESSKA Congress 2012 (Geneve, Zwitserland), NOV Jaarcongres 2013 (Amsterdam), ISAKOS 2013 Congress (Toronto, Canada), AGA Congress 2013 (Wiesbaden, Duitsland).

Abstract:

Purpose: Analysis of long-term clinical and radiological outcome after anterior cruciate ligament (ACL) reconstruction with special attention to knee osteoarthritis and its predictors.

Methods: A prospective, consecutive case series of 100 patients. Arthroscopic transtibial ACL reconstruction was performed using 4 strand hamstring tendon autografts with a standardised accelerated rehabilitation protocol. Analysis was performed preoperatively and 10 years postoperatively. Clinical examination included Lysholm and Tegner scores, IKDC, KT-1000 testing (MEDmetric Co., San Diego, CA) and leg circumference measurements. Radiological evaluation included AP weight bearing, lateral knee, Rosenberg and sky view X-rays. Radiological classifications were according to Ahlbäck and Kellgren & Lawrence. Statistical analysis included univariate and multivariate logistic regressions.

Results:

Clinical outcome: A significant improvement (p<0.001) between preoperative and postoperative measurements could be demonstrated for the Lysholm and Tegner scores, IKDC patient subjective assessment, KT-1000 measurements, pivot shift test, IKDC score and one leg hop test. A pivot shift phenomenon (glide) was still present in 43 (50%) patients and correlated with lower levels of activity (p<0.022).

Radiological outcome:At follow-up, 46 (53.5%) patients had signs of osteoarthritis (OA). In this group, 33 patients (72%) had chondral lesions (≥ grade 2) at time of ACL reconstruction. A history of medial meniscectomy before or at time of ACL reconstruction increased the risk of knee OA 4 times (95% CI 1.41-11.5). An ICRS grade 3 at time of ACL reconstruction increased the risk of knee OA by 5.2 times (95% CI 1.09-24.8). There was no correlation between OA and activity level (Tegner score ≥6) nor between OA and a positive pivot shift test.

Conclusion: Transtibial ACL reconstruction with 4 strand hamstring autograft and accelerated rehabilitation restored anteroposterior knee stability. Clinical parameters and patient satisfaction improved significantly. At ten year follow-up, radiological signs of OA were present in 53.5% of the subjects. Risk factors for OA were meniscectomy prior to, or at time of ACL reconstruction and chondral lesions at time of ACL reconstruction.

Level of evidence: 2
Keywords: anterior cruciate ligament reconstruction – hamstring autograft – knee osteoarthritis – accelerated rehabilitation – long term – radiological