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Randomized Controlled Trial
. 2022 Feb;50(2):384-395.
doi: 10.1177/03635465211061150. Epub 2022 Jan 20.

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience

Andrew D Firth, Dianne M Bryant, Robert Litchfield  1 , Robert G McCormack  2 , Mark Heard  3 , Peter B MacDonald  4 , Tim Spalding  5 , Peter C M Verdonk  6 , Devin Peterson  7 , Davide Bardana  8 , Alex Rezansoff  9 ; STABILITY Study Group; Alan M J Getgood, Kevin Willits, Trevor Birmingham, Chris Hewison, Stacey Wanlin, Ryan Pinto, Ashley Martindale, Lindsey O'Neill, Morgan Jennings, Michal Daniluk  1 , Dory Boyer, Mauri Zomar, Karyn Moon, Raely Moon, Brenda Fan, Bindu Mohan  2 , Gregory M Buchko, Laurie A Hiemstra, Sarah Kerslake, Jeremy Tynedal  3 , Greg Stranges, Sheila Mcrae, LeeAnne Gullett, Holly Brown, Alexandra Legary, Alison Longo, Mat Christian, Celeste Ferguson  4 , Nick Mohtadi, Rhamona Barber, Denise Chan, Caitlin Campbell, Alexandra Garven, Karen Pulsifer, Michelle Mayer  9 , Nicole Simunovic, Andrew Duong, David Robinson, David Levy, Matt Skelly, Ajaykumar Shanmugaraj  7 , Fiona Howells, Murray Tough  8 , Pete Thompson, Andrew Metcalfe, Laura Asplin, Alisen Dube, Louise Clarkson, Jaclyn Brown, Alison Bolsover, Carolyn Bradshaw, Larissa Belgrove, Francis Milan, Sylvia Turner, Sarah Verdugo, Janet Lowe, Debra Dunne, Kerri McGowan, Charlie-Marie Suddens  5 , Geert Declerq, Kristien Vuylsteke, Mieke Van Haver  6   10
Affiliations
Randomized Controlled Trial

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience

Andrew D Firth et al. Am J Sports Med. 2022 Feb.

Abstract

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined.

Purpose/hypothesis: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture.

Study design: Case-control study; Level of evidence, 3.

Methods: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level.

Results: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture.

Conclusion: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Keywords: ACLR failure; anterior cruciate ligament reconstruction; lateral extra-articular tenodesis; predictors.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: A.M.J.G. has received consulting fees from Smith & Nephew, Ossur, and Olympus; royalties from Smith & Nephew and Graymont Inc; and research support (institutional) from the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, Canadian Institutes of Health Research, National Institutes of Health, Academic Medical Organization of Southwestern Ontario, Canada Foundation for Innovation, Ontario Research Foundation, and Smith & Nephew. R.L. has received consulting fees from Smith & Nephew. R.G.M. has received speaking fees from Bioventus, Pendopharm, Smith & Nephew, and Sanofi. T.S. has received speaking fees from ConMed, Smith & Nephew, and Joint Operations and consulting fees from ConMed. P.C.M.V. has received speaking fees from ConMed and Smith & Nephew and consulting fees from ConMed. L.A.H. has received consulting fees from ConMed. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Predicted probability of graft rupture by age with and without the addition of a LET for patients in the Stability 1 Study, adjusted for tibial slope angle, medial meniscal deficiency, high-grade knee laxity, and time of return to sport. ACL, anterior cruciate ligament; LET, lateral extra-articular tenodesis.
Figure 2.
Figure 2.
Predicted probability of graft rupture by tibial slope angle with and without the addition of a LET for patients in the Stability 1 Study, adjusted for age, medial meniscal deficiency, high-grade knee laxity, and time of return to sport. ACL, anterior cruciate ligament; LET, lateral extra-articular tenodesis.
Figure 3.
Figure 3.
Contour plot showing predicted probabilities of graft failure for patients in the Stability 1 Study by age and tibial slope, adjusted for the addition of a LET, high-grade knee laxity, time returned to sport, and deficient medial meniscus. This shows the predicted probability of ACLR rupture from the Stability 1 Study as a function of tibial slope angle and patient age. Predicted probabilities range from approximately 0% to 25%, with greater probability of failure indicated by areas with darker shading. ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis.
See this image and copyright information in PMC

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