What You Need To Know About ACLR Before Reconstruction

In this article we will provide you with some of the latest literature review related to ACL reconstructions, specifically graft type and prevention.  This is intended to provide you with solid, research based information to assist you in making the right decision for the immediate future as well as long term joint health.  So, if you or someone you know tore their ACL, this is a must read. 

In athletics, tearing one’s ACL can be one of the most physically and psychologically devastating injuries.  Many times the injury occurs on the field and then the athlete is evaluated in the MD office the next day and has surgery 1-2 days later.  Many times, ACL ruptures in a Friday Night football game are seen in rehab for post-operative care the following week.  Less than 7 days.  This is great and has a huge impact on the outcome the patient gets but it can also add to a sense of being overwhelmed.  Part of that is an inability to feel completely informed and to obtain reliable information regarding the surgery, the surgeon, the technique used, the graft type and the rehab.  Many times, you are simply trying to still adjust to the shock of the event, get everything arranged and ensure your son, daughter, spouse or self, is ready for this huge surgery.  Yet there is a major psychological component that goes along with this injury.  Part of that is addressed by being informed and educated on options.  Other psychological components can be positively influenced with rehab.  For more information specifically on this, view our blog “Psychological Responses Matter in Return to Sport After ACLR” @  http://aclprevention.blogspot.com/2013_07_01_archive.html.

One of the first questions people always ask when considering this surgery is what type of graft I should have.  Basically, there are 3 choices.

• Allograft – this is a patellar tendon harvested from a donor
• Hamstrings graft – this is a graft harvested from the patient’s semitendinosus (hamstrings) and which is crafted into an ACL
• Patellar tendon graft – this is a graft harvested from the patient’s patella (with a bony plug from the patella and the tibial tubercle) which is crafted into an ACL

Each of these graft types has its positives and its negatives.  Over the course of the last 10-12 years, you have seen trends in graft selection by orthopedic surgeons from one to the other based on the most current research.  Back in the late 90s, there was a movement away from using allografts due to a large number of staph infections that were arising from donor tissue that was not being properly sterilized.  That said, since then sterilization techniques have improved and some physicians use these as the primary selection.  In 2013, Maletis et al published a study looking at infection rates amongst various graft types.  In this study, over a 5 year period, they compared over 10,000 patients who had an ACLR using a hamstrings graft to patellar tendon graft to allograft.  What they found was infection rates below 1% in all graft types.  Although the hamstring grafts had slightly higher rate of infections when compared to the others, it was still well below .5%.  Considering, for the most part, the 2 most common grafts selected today are the patellar tendon graft and hamstrings graft.

When considering laxity, it was always felt that one graft type was superior to another.  In 2007, Pincewski, et al did a study that compared laxity of grafts over a 10 year period.  In this study the compared ACLR using hamstrings grafts and patellar tendon grafts.  What the authors found was that after 10 years there was no variance in laxity when comparing the two groups and no variance in rupture rates between the two.  However, those with hamstrings grafts reported less pain with kneeling, with athletic activity and less signs of radiographic osteoarthritis at the 10 year mark.  So although excellent results seen with both techniques, the authors suggest hamstrings grafts to their patients. 

One fear when selecting graft type is long term instability (increased laxity in ligament) and increased potential for rupture.  Knowing that there is such a high incidence of rupture of the graft in the first 2 years (20% tear) and 79% have OA in 12 years, both of these factors are important to know when choosing graft type.  In 2013, Kamien et al published a study that looked at age, graft size and level of activity’s impact on hamstring grafts rupture rate.  Over 7 years they looked at 98 patients who had undergone an ACLR using the hamstrings tendon.  In this group, 15.3% ruptured (which is below averages for ACL rupture in the first 2 years) in the first 2 years.  Of those that ruptured, 25% were under the age of 25.  Although graft size did not play into it neither did activity level.  That said, authors do acknowledge that those under the age of 25 tend to be more active and when comparing to other studies, those who are over the age of 25 are less likely to return to sport than those under the age or 25.

So what is the take home?  Hamstring grafts tend to have less pain with daily activity and sports and lower rupture rates than published national averages (excluding graft type).  That considered there is a slightly higher incidence of infections and secondary complications with posterior hamstring pain.  But the real take home message should be prevent them before they happen.  In 2013 Gagnier et al published a systematic review and meta-analysis of the literature related to injury prevention programs.  Overall, they found programs to have an estimated effectiveness of ~50%.  Those that were found to be the most effective included a neuromuscular component and educational component.  Of all the research we have, 50% effectiveness on non-contact ACL injuries.  There are better solutions that can have better results.  This study clearly showed that studies that had longer follow up with players, more training hours and increased compliance were more effective.  What if the programs were actually personalized based on the individual’s deficits and exercises were geared to be integrated with practice?  Could and would those results be better?  Studies being conducted right now are showing that.  Using the Dynamic Movement Assessment™ at pre-seasons physicals and developing seasonal training programs based on individual results is not only reducing ACL injury rates but also reducing injury rates from the low back to the foot/ankle.

About the author:  Trent Nessler, PT, DPT, MPT, CEO/Founder of Accelerated Conditioning and Learning (A.C.L.), LLC. He is also the researcher and developer the Dynamic Movement Assessment™ (DMA™), author of the textbook Dynamic Movement Assessment™: Enhance Performance and Prevent Injury, associate editor for the International Journal of Athletic Therapy & Training, and Member of the USA Cheer Safety Council. For more information on how your team can have a pre-season DMA™ or to attend one of their certification courses, go to www.aclprogram.com or contact him directly at drtrent@aclprogram.com.

References:

1. Pinczewski L, Lyman J, Salmon L, Russell V, Roe J, Linklater J.  A 10-Year Comparison of Anterior Cruciate Ligament Reconstructions with Hamstring Tendon and Patellar Tendon Autograft.  Am J Sports Med.  35:564-574. 2007.  
2. Kamien P, Hydrick J, Reloogle W, Go L, Barrett G.  Age, Graft Size and Tegner Activity Level as Predictors of Failure in Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft.  Am J Sport Med.  41:1808-1812. 2013.
3. Maletis G, Inacio M, Reynold S, Desmond J, Maletis M, Funahashi T.  Incidence of Postoperative Anterior Cruciate Ligament Reconstruction Infections: Graft Choice Makes a Difference.  Am J Sport Med.  41:1780-1785. 2013.
4. Gagnier J, Morgenstern H, Chess L.  Interventions Designed to Prevent Anterior Cruciate Ligament Injuries in Adolescents and Adults.  Am J Sport Med.  41:1952-1962. 2013.