For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of May 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Athletes with Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria than Athletes with Hamstring Tendon Autograft or Soft Tissue Allograft.”
Although the title reveals the findings of this retrospective cohort study, the authors emphasize that “athletes in the allograft and HT groups may be at higher risk of sustaining another knee injury when they return to sport…than those in the BPTB group.” Also, all 79 participants in the study were athletes planning to return to level 1 or 2 sporting activities, so these findings may not be generalizable to all athletes.
Sport activity continues to increase in priority in modern society. And with a concomitant increase in single-sport focus early in life and near year-round training, the incidence of knee injuries will also continue to increase. Among surgeons and patients, there has been some waning of interest in high tibial osteotomy (HTO) for the most common form of unicompartmental arthritis because results from unicompartmental arthroplasty keep improving, but HTO remains an appropriate choice for patients with very high functional demand.
In the September 21, 2016 issue of The Journal, Ekhtiari et al. report on the findings of a well-conducted systematic review on return-to-work and -sport outcomes of HTO. The authors found that more than four-fifths of patients returned to work or sport, usually within a year after surgery. Approximately four-fifths of patients returned to sport at a level equal to or greater than their preoperative level, and among non-military patients included in the review, 97.8% returned to work at an equal or greater level.
As with most systematic reviews in orthopaedic surgery, the basic concern here is with the quality of the literature that forms the basis of the analysis. The vast majority of studies included in the review were Level IV case series, which leads to concerns about selection and detection bias. Those concerns notwithstanding, a return to sport activity of 87% at a mean follow-up of longer than 5 years is remarkable.
We must recognize that patients who wish to return to sport are the most highly motivated population we serve. HTO should not fall off our radar screen of options for patients with high functional demand and medial compartment arthritis, for they can be some of the most satisfied patients we treat.
Marc Swiontkowski, MD
The rate of graft failure following anatomic ACL reconstruction has been reported to be as high as 13%, nearly double the reported failure rate of transtibial reconstructions. The majority of anatomic graft failures occur six to nine months after surgery, when patients commonly return to full sports activity. Findings from a cadaver study by Araujo et al. in the November 4, 2015 edition of The Journal of Bone & Joint Surgery may help explain these phenomena.
The authors used a robotic system to measure in situ forces on 12 native cadaver ACLs and on three different reconstructions, one representing the anatomic approach and two reconstructions approximating traditional transtibial approaches. They measured forces on the grafts during anterior tibial loading and simulated pivot-shift loading.
Araujo et al. hypothesized that an anatomically positioned graft would experience increased in situ forces relative to transtibial positioning, and that is what the study revealed during knee flexion angles of 0°, 15°, and 30°. At 45°, 60°, and 90° of flexion, the transtibially positioned grafts experienced higher in situ loading forces than the anatomic ones.
While this cadaveric study is not the definitive word on this matter, with the high graft forces on the anatomic reconstructions, the authors suggest that “rehabilitation and return to sports progression may need to be modified to protect an anatomically placed graft after ACL reconstruction.”