Sports Rehabilitation after ACL Reconstruction Comparing Patellar versus Hamsrtring Autograft in Spa Center Zrece

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1 Sports Rehabilitation after ACL Reconstruction Comparing Patellar versus Hamsrtring Autograft in Spa Center Zrece Short-term versus Long-term Functional Results Assist. Prof. Matjaz Sajovic Department for Orthopedic and Sports Trauma Surgery, General Hospital Celje, Slovenia april 2012 ENSPA Laško 1

2 ACL rupture is the most common serious injury of the knee! Increased participation of all ages in sports has resulted in an increase of the incidence of ACL tears april 2012 ENSPA Laško 2

3 ACL reconstruction is a common procedure that usually allows predictable and timely return to function for the patient. The goals of ACL reconstructions are to decrease symptoms, improve function, and return patients to their pre-injury level of sports activity april 2012 ENSPA Laško 3

4 The surgeon has to choose : graft fixation april 2012 ENSPA Laško 4

5 Prospective, randomized short-term and longterm studies are needed to determine the differences between graft materials april 2012 ENSPA Laško 5

6 It is still not clear if rehabilitation program should be adjusted to graft choice april 2012 ENSPA Laško 6

7 ACL reconstruction Semitendinosus and gracilis tendon autograft (STG) versus Patellar tendon autograft (PT) april 2012 ENSPA Laško 7

8 Study criteria : ACL deficient knee No significant multiple ligament deficiency Without rentgenographic abnormality Prospective Randomized A single surgeon performed all arthroscopic procedures The same post-op. rehabilitation protocol april 2012 ENSPA Laško 8

9 From June 1999 to March patients were randomly assigned: Group I ( 32 patients ) STG autograft Group II ( 32 patients ) PT autograft april 2012 ENSPA Laško 9

10 Operative data single technique, different transplant PT transplant STG transplant april 2012 ENSPA Laško 10

11 ACL reconstruction PT ( patellar tendon autograft ) Versus STG ( semitendinosus and gracilis autograft ) Advantages? Immediate Short-term Long-term april 2012 ENSPA Laško 11

12 Intra and postoperative data ACL reconstruction time ( min. ) Group I PT Group II STG Hospitalization / days 6 3 Parenteral analgesia ( days ) Punctions 4 2 None Once Twice april 2012 ENSPA Laško 12

13 Results of clinical evaluation ( 5 months follow-up ) Group I PT Group II STG Effusion None Mild 2 0 Moderate 0 0 Patellofemoral crepitus None 21 ( 70 % ) 29 ( 97 % ) Mild 6 1 Moderate 3 0 Thigh Atrophy (cm) 0 18 ( 60 % ) 27 ( 90 % ) april 2012 ENSPA Laško 13

14 Results of clinical evaluation ( 5 months follow-up ) Group I PT Group II STG Full ROM 24 ( 80 % ) 30 ( 100 % ) Extension deficit 1 3 deg. 5 ( 16 % ) 0 ( 0 % ) Flexion deficit 10 deg. 6 ( 20 % ) 0 ( 0 % ) Lysholm score excellent 21 ( 70 % ) 25 ( 83 % ) april 2012 ENSPA Laško 14

15 Clinical stability ( 5 months follow-up ) Lachman Group I PT Group II STG 0 21 ( 70 % ) 13 ( 43 % ) Pivot-shift 0 22 ( 73 % ) 17 ( 56 % ) april 2012 ENSPA Laško 15

16 + Patients Measurements with KLT arthrometer at 5 months follow-up 10 Group PT (30 patients) Group STG (30 patients) D mm april 2012 ENSPA Laško 16

17 Artrometer KT april 2012 ENSPA Laško 17

18 Isokinetic Power test ( 5 months follow-up ) Group I PT Group II STG Q deficit ( % ) Female Male H deficit ( % ) 4 8 H / Q ratio 0,86 0, april 2012 ENSPA Laško 18

19 Isokinetic Power test ( 5 months follow-up ) PT group STG group april 2012 ENSPA Laško 19

20 Izokinetični dinamometer april 2012 ENSPA Laško 20

21 CONCLUSIONS! Arthroscopically assisted ACL reconstructions with STG autograft offered significant advantages over PT autograft april 2012 ENSPA Laško 21

22 STG advantages are: reduces pain ( hospitalisation time ) faster rehabilitation less thigh atrophy faster quadriceps recovery less patellofemoral problems april 2012 ENSPA Laško 22

23 11 years follow-up evaluation 54 patients ( 27 women ; 27 men ) STG group 28 patients ( 15 women ; 13 men ) PT group 26 patients ( 12 women ; 14 men ) april 2012 ENSPA Laško 23

24 Comparison of randomized groups Hamstring Patellar Tendon Group Tendon Group P Total number of patients Age, y (range) 24 (14-42) 27 (16-46) Gender Male Female IKDC preinjury activity level Level I Preoperative Lysholm scores 57 (9-82) 55 (16-77).611 Time from injury to surgery (months) 25 (1-84) 23 (1-60) Meniscal surgery april 2012 ENSPA Laško 24

25 Results april 2012 ENSPA Laško 25

26 The mean of Lysholm knee scores at 11 years follow-up was 95 in STG group and 94 in PT group Hamstring tendon group (N=28) Patellar tendon group (N=26) N % N % P Excellent (95-100) Good (84-94) Fair (65-83) Poor (<65) april 2012 ENSPA Laško 26

27 Outcomes of clinical evaluations Hamstrimg Patellar Tendon Tendon Group Group n % n % P Manual Lachman test A B C Manual pivot shift test A B C IKDC instrumental Anteroposterior Translation (KT Arthrometer, 25 flexion) A B C april 2012 ENSPA Laško 27

28 KT-2000 arthrometer measurements STG PT april 2012 ENSPA Laško 28

29 Overall IKDC score Hamstrimg Patellar Tendon Tendon Group Group n % n % P A B C D april 2012 ENSPA Laško 29

30 Radiographic evidence of knee joint osteoarthritis grade B and C was present in 84% (21/25) of patients in the PT group and in 63% (17/27) of patients in the STG group which was statistically significant (P =.008) april 2012 ENSPA Laško 30

31 Twenty-three patients (82%) in the STG group and twenty-three patients (88%) in the PT group were still on their pre-injury level of activity april 2012 ENSPA Laško 31

32 Discussion april 2012 ENSPA Laško 32

33 Anterior knee pain and kneeling pain was only a minor problem 17% in STG group 19% in PT group april 2012 ENSPA Laško 33

34 KT-1000 measurements showed statistically significant difference (P=.021) between men and women in PT group In men 1.1 ± 1.6 mm In women 2.9 ± 2.0 mm april 2012 ENSPA Laško 34

35 Conclusion april 2012 ENSPA Laško 35

36 The patients in the STG group more often reached the excellent result (Lysholm score) and so called normal knee (overall IKDC score) compared to patients in the PT group april 2012 ENSPA Laško 36

37 The development of radiographic osteoarthritis grade B and C was clearly identified in the PT group april 2012 ENSPA Laško 37

38 Thus, hamstring tendons are the authors primary graft choice for anterior cruciate ligament reconstruction, specially for female patients april 2012 ENSPA Laško 38

39 THANK YOU FOR YOUR ATTENTION! april 2012 ENSPA Laško 39

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