Impact of surgical timing on the clinical outcomes of anatomic double-bundle anterior cruciate ligament reconstruction

Transcription

1 ISAKOS th -16 th May Cancun, Mexico Impact of surgical timing on the clinical outcomes of anatomic double-bundle anterior cruciate ligament reconstruction Baba R. 1, Kondo E. 2, Iwasaki K. 1, Joutoku Z. 1, Onodera J. 3, Onodera T. 1, Yagi T. 3, Iwasaki N. 1, Yasuda K. 3 1) Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan 2) Department of Advanced Therapeutic Research for Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan 3) Department of Orthopaedic Surgery, Yagi Orthopaedic Hospital, Sapporo, Japan

2 Impact of surgical timing on the clinical outcomes of anatomic double-bundle anterior cruciate ligament reconstruction Rikiya Baba MD, PhD I have no conflict.

3 Backgrounds Impact of surgical timing for ACL injury ROM Arthrofibrosis Shelbourne et al. AJSM ) No influence Hunter et al. Arthroscopy ) Lysholm score, IKDC evaluation Worse in delayed surgery Ahlen et al. KSSTA ) No influence Barenius et al. AJSM ) Associated injuries (meniscus, cartilage) Increase in delayed surgery Maffulli et al. Arthroscopy ) Optical surgical timing is still controversial

4 Backgrounds and purpose Anatomic double-bundle ACLR Yasuda et al. Arthroscopy ) Superior knee stability than SB ACL-R Kondo et al. AJSM ) AMB and PLB were clearly visible at 2 years after surgery Kondo et al. Arthroscopy ) Impact of surgical timing on clinical outcomes remains unclear The purpose of this study is To clarify clinical outcomes after anatomic DB ACL-R among the difference of surgical timing

5 Materials and Methods 179 patients: unilateral ACL injury Anatomic DB ACL-R Group Injury-to-operation interval Number I within 1 month 26 patients II 1 3 months 77 patients III 3 6 months 41 patients IV 6 24 months 35 patients Clinical 2 years postoperatively Background factors Knee stability, Lysholm score, IKDC evaluation Associated injuries

6 Results Background factors and pre-operative evaluations Male : Female ratio (cases) Age α (years) I (n = 26) II (n = 77) III (n = 41) IV (n = 35) p value 14 : : : : 14 N.S (11.5) BMI α 22.8 (2.3) Anterior knee laxity α (mm) 3.8 (2.6) 26.4 (11.4) 23.5 (3.3) 3.6 (3.2) 27.1 (12.9) 23.5 (3.3) 4.8 (3.0) 28.1 (14.6) 24.0 (3.5) 4.4 (2.5) N.S. N.S. N.S. Muscle strengths α (%) Quad. 71 (19) 69 (22) 79 (19) 82 (18) β Ham. 71 (21) 71 (25) 84 (23) 87 (27) γ α Data are expressed as mean (S.D.) β Post-hoc;II vs IV, p= γ Post-hoc;II vs IV, p=0.0173

7 Results Post-operative knee instability Anterior knee laxity 0.5 (mm) α (1.8) I II III IV p value 1.1 (1.7) 1.3 (1.5) 1.3 (1.8) N.S. Pivot-shift test (-) 88% 79% 81% 63% (+) 12% 18% 12% 34% (2+) 0% 3% 7% 3% β α Data are expressed as mean (S.D.) β Cochran-Armitage trend test

8 Results Post-operative clinical evaluations Lysholm score α (points) IKDC (cases) I II III IV p value 97 (4) 96 (5) 98 (5) 96 (4) N.S. A B C N.S. Loss of motion (cases) Muscle strengths α (%) Ext > N.S. Flex> N.S. Quad. 90 (14) 89 (16) 84 (22) 87 (18) N.S. Ham. 97 (16) 91 (19) 91 (22) 86 (20) N.S. α Data are expressed as mean (S.D.)

9 Results Associated injuries Medial meniscus injury (%) * : ICRS grade 2-4 Medial compartment chondral injury* (%) Repair rate of meniscus lesion α α α α Cochran-Armitage trend test

10 Discussions Pre-operative muscle strengths were significantly weaker in Group II than in Group IV. Post-operative pivot-shift test was significantly better in early surgery group. Significantly higher rates of MM injury and medial compartment chondral injury were seen in delayed surgery group compared to early cases.

11 Discussions Post-operative knee stability with respect to surgical timing Author Journal Early Delayed Graft type follow-up Results Barenius et al. 4) Raviraj et al. 9) Sgaglione et al. 10) Ahn et al. 11) AJSM 2010 JBJS 2010 AJSM 1993 KSSTA 2016 <5M 5M< PT/ST 8 yr N.S. <2w 4w< STG 32 M N.S. <3w 6w< ST 36 M Early is better <12w 12w< STG 55 M Early is better Current study Significantly better in early surgery

12 Discussions Associated injury with respect to surgical timing Author Journal Medial meniscal and chondral injuries Magnussen et al. 12) KSSTA 2013 Increase after 3 months Brambilla et al. 13) AJSM 2015 Increase after 12 months MM is a secondary restraint to anterior drawer of the knee Delayed surgery led to higher rate of MM and chondral lesion Earlier ACLR may be beneficial for patients to stabilize and prevent secondary damages of the ACL injured knee.

13 Conclusions Pre-operative muscle strengths were significantly weaker in early surgery group than in delayed surgery group. Post-operative pivot-shift test was significantly better in early surgery group. Significantly higher rate of MM injury and medial compartment chondral injury was seen in cases of delayed surgery compared to early cases.

14 References 1. Ahlen M, Liden M. A comparison of the clinical outcome after anterior cruciate ligament reconstruction using a hamstring tendon autograft with special emphasis on the timing of the reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19(3): Ahn JH, Lee SH. Risk factors for knee instability after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016;24(9): Barenius B, Nordlander M, et al. Quality of life and clinical outcome after anterior cruciate ligament reconstruction using patellar tendon graft or quadrupled semitendinosus graft: an 8-year follow-up of a randomized controlled trial. Am J Sports Med. 2010;38(8): Brambilla L, Pulici L, et al. Prevalence of Associated Lesions in Anterior Cruciate Ligament Reconstruction: Correlation With Surgical Timing and With Patient Age, Sex, and Body Mass Index. Am J Sports Med. 2015;43(12): Hunter RE, Mastrangelo J, et al. The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction. Arthroscopy. 1996;12(6): Kondo E, Yasuda K, et al.. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med. 2008;36(9): Kondo E, Yasuda K, et al. Radiologic evaluation of femoral and tibial tunnels created with the transtibial tunnel technique for anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2007;23(8): Maffulli N, Binfield PM, et al.. Articular cartilage lesions in the symptomatic anterior cruciate ligament-deficient knee. Arthroscopy. 2003;19(7): Magnussen RA, Pedroza AD, et al. Time from ACL injury to reconstruction and the prevalence of additional intra-articular pathology: is patient age an important factor? Knee Surg Sports Traumatol Arthrosc. 2013;21(9): Raviraj A, Anand A, et al. A comparison of early and delayed arthroscopically-assisted reconstruction of the anterior cruciate ligament using hamstring autograft. J Bone Joint Surg Br. 2010;92(4): Sgaglione NA, Del Pizzo W, et al. Arthroscopically assisted anterior cruciate ligament reconstruction with the pes anserine tendons. Comparison of results in acute and chronic ligament deficiency. Am J Sports Med. 1993;21(2): Shelbourne KD, Wilckens JH, et al. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991;19(4): Yasuda K, Kondo E, et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy. 2004;20(10):