Clinical failure of anterior cruciate ligament (ACL) reconstructions continues to be a too-common scenario. The increasing incidence of ACL revision is due to a variety of factors, including greater intensity of postsurgical physical activity, technical issues, and anatomical influences of the proximal tibia and distal femur. Registries are important sources of data for ACL-related investigations, but I think they are most useful in clarifying experimental designs for more sophisticated clinical research.
In a cohort study in the October 16, 2019 issue of The Journal, Snaebjornsson et al. examined the influence of ACL graft diameter on the risk of revision surgery over 2 years in >18,000 subjects whose data resided in the national knee ligament registries of Sweden and Norway. The vast majority of those patients (92.8%) received a hamstring autograft, with 7.2% receiving a patellar tendon autograft. Overall, the 2-year rate of ACL revision was 2.63% for patellar tendon autografts and 2.08% for hamstring autografts, a statistically nonsignificant difference in relative risk.
However, the authors found an important correlation between graft diameter in the hamstring tendon cohort, with autografts <8 mm in diameter being associated with a higher risk of revision, compared with larger-diameter hamstring autografts. Additionally, patients treated with hamstring graft diameters of ≥9 mm or ≥10 mm had a lower risk of ACL revision surgery than those treated with patellar tendon grafts of any size.
One key limitation that should influence our interpretation of this study is a lack of detail regarding how compliant surgeons were intraoperatively with the use of the measurement device that is depicted in the manuscript and shown above. In addition, the limitations of registry data did not permit the authors to adjust for postsurgical exposures, such as return to sport, the increasing intensity of which makes rerupture more likely. Additional relevant information that would have aided interpretation of the findings includes the relative size of the tibia and femur, lateral condyle size and shape, and proximal tibial slope.
Despite these limitations, this study should prompt further research that uses robust clinical designs to more fully investigate the impact of graft diameter on ACL rerupture rates.
Marc Swiontkowski, MD
From journal articles to nightly news segments, it’s hard to avoid the barrage of information related to the use of cell-based therapies for musculoskeletal problems. While these approaches may turn out to be enthusiasm outpacing science (see related OrthoBuzz post, “Stemming the Tide of Stem Cell Hype”), one reason for the excitement is rooted in a very simple fact: it is really hard to get many soft tissues to heal, especially in certain patient populations. Moreover, failure of initial repair usually leads to even more biologically inhospitable repair environments. This clinical challenge has led to the zealous investigation of various cell-based compounds to see which ones might assist native soft-tissue cells with the formidable task of quick healing.
In the July 3, 2019 issue of The Journal, Ma et al. investigate the potential for human placenta-derived cells to augment the healing of chemically induced patellar tendon ruptures in rats. The injected placental cells introduced a transitory inflammatory response that led to increased load to failure at the 2-week mark, compared to biomechanical results in control rat tendons injected with saline solution. However, the addition of placenta-derived cells did not increase tendon load to failure beyond 2 weeks, and at no time point were differences seen between the control and experimental groups in tendon strength, stiffness, collagen organization, or cellularity.
While the positive results of this study were short-lived, they are important nonetheless. The animal model used is well thought-out and reproducible, allowing an easy path for future investigators to compare and contrast these results. Placenta-derived cell populations are widely available, and the authors clearly explained how the cells were processed, preserved, and delivered. With the increasing incidence of acute and chronic tendon injuries, and with the results of studies using other cell types being equivocal at best, these findings from Ma et al. are noteworthy.
Marc Swiontkowski, MD