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Clinical Trial
. 2018 Oct;46(12):2836-2841.
doi: 10.1177/0363546518777732. Epub 2018 Jun 8.

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group

MARS Group  1 ; Daniel E Cooper  1 , Warren R Dunn  1 , Laura J Huston  1 , Amanda K Haas  1 , Kurt P Spindler  1 , Christina R Allen  1 , Allen F Anderson  1 , Thomas M DeBerardino  1 , Brett Brick A Lantz  1 , Barton Mann  1 , Michael J Stuart  1 , John P Albright  1 , Annunziato Ned Amendola  1 , Jack T Andrish  1 , Christopher C Annunziata  1 , Robert A Arciero  1 , Bernard R Bach Jr  1 , Champ L Baker 3rd  1 , Arthur R Bartolozzi  1 , Keith M Baumgarten  1 , Jeffery R Bechler  1 , Jeffrey H Berg  1 , Geoffrey A Bernas  1 , Stephen F Brockmeier  1 , Robert H Brophy  1 , Charles A Bush-Joseph  1 , J Brad Butler V  1 , John D Campbell  1 , James L Carey  1 , James E Carpenter  1 , Brian J Cole  1 , Jonathan M Cooper  1 , Charles L Cox  1 , R Alexander Creighton  1 , Diane L Dahm  1 , Tal S David  1 , David C Flanigan  1 , Robert W Frederick  1 , Theodore J Ganley  1 , Elizabeth A Garofoli  1 , Charles J Gatt Jr  1 , Steven R Gecha  1 , James Robert Giffin  1 , Sharon L Hame  1 , Jo A Hannafin  1 , Christopher D Harner  1 , Norman Lindsay Harris Jr  1 , Keith S Hechtman  1 , Elliott B Hershman  1 , Rudolf G Hoellrich  1 , Timothy M Hosea  1 , David C Johnson  1 , Timothy S Johnson  1 , Morgan H Jones  1 , Christopher C Kaeding  1 , Ganesh V Kamath  1 , Thomas E Klootwyk  1 , Bruce A Levy  1 , C Benjamin Ma  1 , G Peter Maiers 2nd  1 , Robert G Marx  1 , Matthew J Matava  1 , Gregory M Mathien  1 , David R McAllister  1 , Eric C McCarty  1 , Robert G McCormack  1 , Bruce S Miller  1 , Carl W Nissen  1 , Daniel F O'Neill  1 , Brett D Owens  1 , Richard D Parker  1 , Mark L Purnell  1 , Arun J Ramappa  1 , Michael A Rauh  1 , Arthur C Rettig  1 , Jon K Sekiya  1 , Kevin G Shea  1 , Orrin H Sherman  1 , James R Slauterbeck  1 , Matthew V Smith  1 , Jeffrey T Spang  1 , Steven J Svoboda  1 , Timothy N Taft  1 , Joachim J Tenuta  1 , Edwin M Tingstad  1 , Armando F Vidal  1 , Darius G Viskontas  1 , Richard A White  1 , James S Williams Jr  1 , Michelle L Wolcott  1 , Brian R Wolf  1 , James J York  1 , Rick W Wright  1
Affiliations
Clinical Trial

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group

MARS Group et al. Am J Sports Med. 2018 Oct.

Abstract

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture.

Study design: Cohort study; Level of evidence, 2.

Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR.

Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03).

Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Keywords: anterior cruciate ligament; graft failure; graft tensioning; knee hyperextension.

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Figures

Figure 1
Figure 1. Odds Ratios for Age, Graft and Hyperextension
Median age was 26 (IQR 35:20). Increased odds ratio of graft failure was associated with young age (OR 3.6), allograft (OR 3.3) and HE≥5 (2.12).
See this image and copyright information in PMC

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References

    1. Akelman MR, Fadale PD, Hulstyn MJ, et al. Effect of Matching or Over-constraining Knee Laxity During Anterior Cruciate Ligament Reconstruction on Knee Osteoarthritis and Clinical Outcomes: A Randomized Controlled Trial with 84-Month Follow-up. Am J Sports Med. 2016 Jul;44(7):1660–70. - PMC - PubMed
    1. Benner RW, Shelbourne KD, Gray T. The degree of knee extension does not affect postoperative stability or subsequent graft tear rate after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2016 Apr;44(4):844–9. [Epub ahead of print] - PubMed
    1. Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW, MOON Consortium and the MARS Group Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med. 2011 Sep;39(9):1889–93. [Epub ahead of print] - PMC - PubMed
    1. Brophy RH, Haas AK, Huston LJ, Nwosu SK, MARS Group. Wright RW. Association of meniscal status, lower extremity alignment, and body mass index with chondrosis at revision anterior cruciate ligament reconstruction. Am J Sports Med. 2015 Jul;43(7):1616–22. [Epub ahead of print] - PMC - PubMed
    1. Brophy RH, Wright RW, David TS, McCormack RG, Sekiya JK, Svoboda SJ, Huston LJ, Haas AK, Steger-May K, Multicenter ACL Revision Study (MARS) Group Association between previous meniscal surgery and the incidence of chondral lesions at revision anterior cruciate ligament reconstruction. Am J Sports Med. 2012 Apr;40(4):808–14. [Epub ahead of print] - PMC - PubMed

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