Reconstruccion del tendon de cuadriceps, Apuntes de Traumatología

¡Descarga Reconstruccion del tendon de cuadriceps y más Apuntes en PDF de Traumatología solo en Docsity! Page 1 of 14 Quadriceps Tendon (QT) ACL Reconstruction Scientific Update QT ACL reconstruction (ACLR) continues to be one of the fastest growing ACLR techniques performed worldwide. The clinical benefits of the QT technique – including robust and predictable graft sizing, superior biomechanics, equal or better clinical outcomes, low morbidity, and improved cosmesis – are now supported in a number of clinical and biomechanical studies as well as systematic reviews. This update summarizes the scientific support for successful outcomes with the QT technique. In Vivo Studies: Clinical Outcomes Hunnicutt JL, Haynes WB, Slone HS, Prince JA, Boden SA, Xerogeanes JW The all-soft tissue quadriceps tendon autograft in revision ACL reconstruction: early and intermediate-term outcomes in 100 patients. Arthroscopy. 2021;S0749-8063(21)00258-9. doi:10.1016/j.arthro.2021.03.035 ■ This retrospective review of prospectively collected data from consecutive patients sought to examine early- to intermediate-term clinical outcomes and complications of revision ACLR using QT autografts. ■ One hundred patients undergoing revision ACLR with all-soft tissue QT autografts were included. All procedures were performed by a single surgeon (Xerogeanes), using minimally invasive harvest technique and suspensory fixation. ■ It was concluded that revision ACLR using QT autografts has acceptable early- and intermediate-term outcomes with reasonable complication rates. ■ Importantly, in the patients with prior bone-patellar tendon-bone (BPTB) surgery, secondary insult to the extensor mechanism via QT autograft harvest does not adversely affect strength compared to patients with hamstring tendon (HT) autograft in the primary operation. Horstmann H, Petri M, Tegtbur U, Felmet G, Krettek C, Jagodzinski M Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial. Arch Orthop Trauma Surg. 2021;10.1007/ s00402-021-03862-8. doi:10.1007/s00402-021-03862-8 ■ This prospective, randomized controlled trial study compared functional outcomes after ACLR using HT and QT grafts with follow-up at 3, 6, 12, and 24 months. ■ Both grafts demonstrated significantly improved knee stability measured by manual side- to-side displacement at all time intervals with no difference between the two study groups in muscle strength and outcome stores. ■ The most important finding of this study was that QT grafts yield good results compared to HT grafts in primary autograft ACLR at 2-year follow-up. ■ Of note was that patients receiving a QT graft exhibited a faster average return to preinjury activity level than those receiving a HT graft, and patients receiving a QT graft did not exhibit any extension strength deficit. Please note: Study abstract can be accessed by clicking on the journal title. Page 2 of 14 In Vivo Studies: Clinical Outcomes Lind M, Strauss MJ, Nielsen T, Engebretsen L Low surgical routine increases revision rates after quadriceps tendon autograft for anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Registry. Knee Surg Sports Traumatol Arthrosc. 2020;10.1007/s00167-020-06220-0. doi:10.1007/s00167-020-06220-0 ■ This study used data entered in the Danish Knee Ligament Reconstruction Registry (DKRR) from 2012 to 2019 to compare revision rates in patients who received ACLR with QT, HT, and patellar tendon (PT) grafts. ■ The study determined that revision rates for QT autograft ACLR performed at high-volume clinics (>100 procedures) were significantly lower (2.9%) compared to low-volume clinics (0 to 100 procedures). ■ The authors concluded that the most important finding of the present study was that the high-volume clinics obtained similar revision outcomes for QT, HT, and PT grafts. This is in contrast with a recent study from the same authors that found a high revision rate for QT grafts compared with HT and PT grafts. Runer A, Csapo R, Hepperger C, Herbort M, Hoser C, Fink C Anterior cruciate ligament reconstructions with quadriceps tendon autograft result in lower graft rupture rates but similar patient-reported outcomes as compared with hamstring tendon autograft: a comparison of 875 patients. Am J Sports Med. 2020;48(9):2195-2204. doi:10.1177/0363546520931829 ■ This was a prospective Level 3 cohort study of 875 patients at 2-year follow-up to compare QT and HT autograft in terms of rates of graft and collateral ACL rupture as well as patient- reported outcome measures. ■ The authors found that graft type, age group, and activity levels were significant predictors of the need for a revision surgery. • “The odds of revision surgery were 5.5 times greater in children younger than 15 years than in adults older than 45 years, 3.6 times greater in patients with high activity levels than low activity levels, and 2.7 times greater in patients receiving an HT autograft as compared with a QT autograft.” ■ “Patients treated with HT autografts have a significantly higher, activity-dependent risk of revision surgery and experience more ipsilateral graft ruptures than subsequent contralateral ACL injuries when compared with patients treated with QT autografts.” Lind M, Nielsen TG, Soerensen OG, Mygind-Klavsen B, Faunø P Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial. Br J Sports Med. 2020;54(3):183-187. doi:10.1136/ bjsports-2019-101000 ■ This randomized controlled trial (RCT) evaluated QT or semitendinosus and gracilis (STG) hamstring tendon (HT) grafts used for patients undergoing ACLR. The authors compared subjective outcome, knee stability, donor-site morbidity, and function. ■ “At 2-year follow-up, there was no difference between the two graft groups regarding subjective patient outcome, knee stability and reoperations. Also, at 2 years, donor site symptoms were present in 27% of patients in the QT group and 50% of patients in the STG group. The donor site morbidity score was 14 and 22 for the QT and STG, respectively.” ■ The authors concluded that “QT graft for ACLR did not result in inferior subjective outcome compared with STG graft. However, QT graft was associated with lower donor site morbidity than STG grafts but resulted in more quadriceps muscle strength deficiency than hamstring grafts. Both graft types had similar knee stability outcome.” Page 5 of 14 In Vivo Studies: Clinical Outcomes Cavaignac E, Coulin B, Tscholl P, Nik Mohd Fatmy N, Duthon V, Menetrey J Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? a comparative study with a mean follow-up of 3.6 years. Am J Sports Med. 2017;45(6):1326-1332. doi:10.1177/0363546516688665 ■ This is a comparative study of 95 patients who underwent isolated ACLR; 50 patients underwent ACLR with QT and 45 underwent ACLR with HT. ■ Of the 95 patients, 86 were reviewed with a mean follow-up of 3.6 ± 0.4 years. ■ Assessment methods included various parameters: surgical revision, functional outcomes, joint stability, anterior knee pain, and isokinetic strength. ■ The authors concluded that the “use of a QT graft in ACL reconstruction leads to equal or better functional outcomes than does the use of an HT graft, without affecting morbidity.” Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study. Arthroscopy. 2014;30(5):593-598. doi:10.1016/j.arthro.2014.01.012 ■ This prospective, randomized controlled study compared quadriceps tendon-bone (QTB) and BPTB reconstructions. ■ The study included 51 patients; 26 patients received QTB grafts and 25 received BPTB. ■ The authors concluded that use of QTB results in less kneeling pain, graft-site pain, and sensitivity loss than BPTB. Similar anterior knee stability and subjective outcome scores were reported. Runer A, Wierer G, Herbst E, et al There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):605-614. doi:10.1007/s00167-017-4554-2 ■ In this 2-year patient-reported outcomes study, 80 patients were evaluated; 40 patients underwent ACLR with QT and 40 underwent ACLR with HT. ■ There was no significant difference between PRO scores in either QT or HT autografts. Both QT and HT show acceptable and comparable PRO scores, thereby reaffirming QT as a reliable graft choice for primary ACLR. Iriuchishima T, Ryu K, Okano T, Suruga M, Aizawa S, Fu FH The evaluation of muscle recovery after anatomical single-bundle ACL reconstruction using a quadriceps autograft. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1449-1453. doi:10.1007/s00167-016-4124-z ■ Twenty patients were included in the study and were evaluated for muscle recovery at pre-op and at 3, 6, 9, and 12 months post-op. ■ Authors found that “anatomical single-bundle ACL reconstruction using a quadriceps autograft resulted in equivalent level of muscle recovery and knee stability when compared with previously reported ACL reconstruction using hamstrings tendon with no donor site complications.” ■ No donor-site complications were reported. Page 6 of 14 In Vivo Studies: Clinical Outcomes Geib TM, Shelton WR, Phelps RA, Clark L Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate- term outcome. Arthroscopy. 2009;25(12):1408-1414. doi:10.1016/j.arthro.2009.06.004 ■ This clinical study of 191 patients (198 reconstructions) compared the intermediate-term outcomes of ACLR using BTBP graft, BQT, and QT. ■ A variety of assessments were used, including a side-to-side comparison of range of motion, arthrometer values, presence of effusion, anterior knee pain, and numbness. The QT autograft showed significantly better results when compared to BTB with less anterior knee pain, less anterior numbness, a higher percentage of arthrometer measurements showing a side-to-side difference of 0 mm to 3 mm, and better extension. ■ This study concluded that ACLR using QT autograft, either with or without a bone plug, is an effective surgical option for reducing donor-site morbidity. The authors found that QT autografts produce “equivalent results when compared directly with BTB autografts in arthroscopically assisted ACLR.” Ma Y, Murawski CD, Rahnemai-Azar AA, Maldjian C, Lynch AD, Fu FH Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2015;23(3):661-668. doi:10.1007/s00167-014-3302-0 ■ This comparative study evaluated 26 patients for potential differences associated with graft maturity on MRI between quadriceps tendon with BQT and HS autografts at 6 months after ACLR. ■ The signal/noise quotient was calculated to evaluate the difference between BQT and HT autografts. ■ The QT tendon with bone block demonstrated better maturity when compared to HT at 6 months post-ACLR. The authors concluded that “this study is clinically relevant in that modifying the individual rehabilitation according to the extent of graft maturity may be necessary to optimize patient function and prevent re-injury of the ACL graft.” Martin-Alguacil JL, Arroyo-Morales M, Martín-Gomez JL, et al Strength recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players: a randomized controlled trial. Knee. 2018;25(4):704-714. doi:10.1016/j.knee.2018.03.011 ■ A randomized controlled trial placed 56 patients into either the HT or QT group. ■ ACLR with QT graft demonstrated similar functional results with a better isokinetic hamstring/quadriceps ratio compared to ACLR with HT graft. Page 7 of 14 Systematic Reviews and Meta-analysis Dai W, Leng X, Wang J, Cheng J, Hu X, Ao Y Quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2021;3635465211030259. doi:10.1177/03635465211030259 ■ A meta-analysis comparing QT to BPTB and HT autografts for ACLR, including 24 randomized controlled trials and observational studies with data on 19,196 patients. ■ No significant differences were noted between QT and BPTB or HT in graft failure, IKDC scores, or side-to-side difference in stability. However, there was a significant reduction in donor-site morbidity in the QT group compared to both the BPTB and HT groups. ■ The authors noted that surgical incisions to the anteromedial knee, including BPTB and HT harvest, are associated with an elevated risk of iatrogenic damage to the infrapatellar branch of the saphenous nerve, which innervates the skin of the anterior part of the knee, the proximal lateral part of the lower leg, and part of the knee joint, resulting in increased donor-site morbidity. Crum RJ, Kay J, Lesniak BP, Getgood A, Musahl V, de Sa D Bone versus all soft tissue quadriceps tendon autografts for anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. 2021;37(3):1040-1052. doi:10.1016/j. arthro.2020.10.018 ■ This study examined existing literature for patient-reported and objective outcomes as well as complications after ACLR with bone-quad-tendon (B-QT) or soft tissue-quad tendon (S-QT) to further evaluate how both graft types perform. ■ The work of 24 studies was evaluated after screening an initial 1346 for information about primary ACLR using QT. ■ The main findings were that B-QT patients demonstrated more postoperative rotatory instability, as assessed by pivot shift, than S-QT patients. Increased rotatory instability is associated with poorer patient outcomes. ■ No differences were found in graft retear rates. The rate of B-QT patellar fracture in this review is like that of BPTB (0.2% to 2.3%) Nyland J, Collis P, Huffstutler A, et al Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):509-518. doi:10.1007/s00167-019-05720-y ■ HT autograft ACLR or QT autograft ACLR were searched in Embase and PubMed with appropriate inclusion criteria to compare QT and HT anterior laxity, pivot shift laxity, and failure rates. ■ The authors concluded QT autografts had less pivot shift laxity and lower failure rates than HT regardless of suspensory or compression femoral fixation. ■ “Greater knee laxity and failure rates may be related to a combination of HT autograft diameter and configuration variability and fixation mode.” Page 10 of 14 Systematic Reviews and Meta-analysis Mulford JS, Hutchinson SE, Hang JR Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(8):1882-1888. doi:10.1007/ s00167-012-2212-2 ■ The purpose of this systematic review was to determine the suitability of QT autografts for primary ACLR. ■ Seventeen articles met the inclusion criteria with 1580 reconstructions studied. ■ The authors concluded that a QT autograft “is a promising alternative for primary ACL reconstructions with good outcomes and minimal donor site morbidity.” Todor A, Nistor D, Roman M, et al Autograft options for ACL reconstruction. which is best? J Interdiscip Med. 2017;2(s3):32-34. doi:10.1515/jim-2017-0042 ■ This clinical update reviews ACL autograft options, highlighting the main characteristics and clinical data for each autograft. ■ The authors concluded that “autografts for ACL reconstruction provide similar functional outcomes.” QT are versatile grafts with results similar to BTB but with less donor-site morbidity. Page 11 of 14 In Vitro Studies: Biomechanical Validation Karkosch RF, Ettinger M, Bachmaier S, Wijdicks CA, Smith T Adjustable-length loop cortical button versus interference screw fixation in quadriceps tendon anterior cruciate ligament reconstruction: a biomechanical in vitro study. Clin Biomech (Bristol, Avon). 2018;60:60-65. doi:10.1016/j.clinbiomech.2018.10.001 ■ This biomechanical cadaveric in vitro study evaluated and compared the “dynamic elongation behavior and ultimate failure strength of tibial adjustable-length loop cortical button versus interference screw fixation in quadriceps tendon-based anterior cruciate ligament reconstruction.” ■ Tibial interference screw fixation showed no statistically significant differences in the initial, dynamic, and total elongation compared to adjustable-loop device fixation. ■ QT ACLR using a tibial adjustable-loop cortical button “provides for comparable dynamic stabilization of the knee with increased ultimate failure-load at decreased stiffness compared to screw fixation.” Shani RH, Umpierez E, Nassert M, Hiza EA, Xerogeanes J Biomechanical comparison of quadriceps and patellar tendon grafts in anterior cruciate ligament reconstruction. Arthroscopy. 2016;32(1):71-75. doi:10.1016/j.arthro.2015.06.051 ■ This study quantified the structural and material properties of 10 mm sections of QT and BPTB grafts. ■ The cross-sectional area of the QT graft was nearly twice that of the BPTB graft. ■ Biomechanical properties were significantly higher for QT compared to BPTB as measured by ultimate load and stiffness. Variability in cross-sectional area was similar in both graft choices. ■ This study reaffirms that QT is a suitable option for ACLR. Urchek R, Karas S Biomechanical comparison of quadriceps and 6-strand hamstring tendon grafts in anterior cruciate ligament reconstruction. Orthop J Sports Med. 2019;7(10):2325967119879113. doi.org/10.1177/2325967119879113 ■ The goal of the study was to compare the biomechanical properties of the QT and the 6-strand HT graft. The measures that were evaluated included graft characteristics, ultimate load-to-failure, load at 3 mm of displacement, and stiffness. ■ The mean diameters of the QT and 6-strand HS were 10.16 mm and 11.33 mm. Despite the size disparity, no differences were found in ultimate load or load at 3 mm of displacement. Both grafts were stiffer than the native ACL. ■ The authors concluded that the quadriceps tendon is a reliable alternative to a 6-strand HT graft for ACLR. Sasaki N, Farraro KF, Kim KE, Woo SL Biomechanical evaluation of the quadriceps tendon autograft for anterior cruciate ligament reconstruction: a cadaveric study. Am J Sports Med. 2014;42(3):723-730. doi:10.1177/0363546513516603 ■ This study measured the 6 degrees of freedom knee kinematics and in situ graft forces after ACLR with QT graft compared with quadrupled STG graft. ■ Ten human cadaveric knees were tested in 3 conditions: intact, ACL deficient, and after ACLR. ■ There were no significant differences between the grafts under any experimental condition. ■ “The positive biomechanical results of the study lend support to the use of QT autograft for ACL reconstruction, as it could restore knee function immediately under applied loads that mimic clinical examinations.” Page 12 of 14 In Vitro Studies: Biomechanical Validation Stäubli HU, Schatzmann L, Brunner P, Rincón L, Nolte LP Mechanical tensile properties of the quadriceps tendon and patellar ligament in young adults. Am J Sports Med. 1999;27(1):27-34. doi:10.1177/03635465990270011301 ■ The authors analyzed biomechanical properties of 16 full-thickness QT and patellar ligament (PL) grafts from paired knees. ■ Preconditioned PL grafts exhibited significantly higher elastic modulus than QT grafts. ■ The QT construct may represent a versatile alternative graft in primary and revision ACL and posterior cruciate ligament (PCL) reconstruction.