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Closure of Patellar Tendon Defect in ACL Reconstruction

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Closure of Patellar Tendon Defect in ACL Reconstruction Systematic Review Closure of Patellar Tendon Defect in Anterior Cruciate Ligament Reconstruction With BoneePatellar TendoneBone Autograft: Systematic Review of Randomized Controlled Trials Rachel M. Frank, M.D., Randy Mascarenhas, M.D., Marc Haro, M.D., Nikhil N. Verma, M.D., Brian J. Cole, M.D., M.B.A., Charles A. Bush-Joseph, M.D., and Bernard R. Bach Jr., M.D. Purpose: This study aimed to systematically review the highest level of evidence on anterior cruciate ligament (ACL) reconstruction with boneepatellar tendonebone (BPTB) autografts with patellar tendon defect closure versus no closure after surgery. Methods: We performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Level I and Level II randomized controlled trials comparing patellar tendon defect closure to no closure during ACL reconstruction with BPTB autografts were included. Two inde- pendent reviewers analyzed all studies. Descriptive statistics were calculated. Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS) and Jadad scale. Results: Four studies with a combined 221 patients (154 male patients and 67 female patients) with an average age of 26.6 Æ 2.4 years (range, 17 to 54 years) were included. All studies randomized patients before surgery into ACLR with BPTB autografts either with patellar tendon defect closure or without closure. There were no differences in clinical outcomes (Lysholm score, Tegner scale, International Knee Documentation Committee [IKDC] classification, modified Larsen score, and Lauridsen rating) between groups. There were no significant differences in knee pain between groups. All studies reported imaging findings of the patellar tendon defect, with 2 studies showing no difference in appearance between groups, one study showing excessive scar formation with defect repair, and one study showing improved restoration of normal tendon appearance with defect repair. The overall quality of the studies was poor, with all studies scoring less than 46 (average, 40.5 Æ 4.7) on the MCMS and scoring 1 on the Jadad scale. Conclusions: Based on this systematic review of 4 randomized trials, there are no statistically significant or clinically relevant differences in outcomes between patients who have the patellar tendon defect closed and those who have it left open after ACLR with BPTB autografts. The methodology of the included studies limits the interpretation of the data, as evidenced by low MCMS and Jadad scores. Level of Evidence: Level II, systematic review of Level I and Level II studies. nterior cruciate ligament (ACL) injuries remain performed, with the goal of restoring knee stability, Aextremely common in the young athletic patient improving function for activities of daily living and sport, population, with an estimated 250,000 ACL injuries and preventing future articular cartilage or meniscal sustained per year in the United States.1,2 For the ma- deterioration, or both.3 ACLR can be performed jority of these patients, ACL reconstruction (ACLR) is through a variety of techniques and with a variety of grafts. Graft choices include either autogenous tissue From Department of Orthopedic Surgery, Rush University Medical Center, (central-third boneepatellar tendonebone [BPTB], Chicago, Illinois, U.S.A. hamstring, and quadriceps autografts) or allograft tissue The authors report the following potential conflict of interest or source of funding: (BTPB, hamstring, Achilles, tibialis anterior, and so on).4 B.J.C. and N.N.V. receive support from Arthrex, DJ Orthopedics, Zimmer, The most commonly used graft for ACLR is the BPTB Regentis, Carticept, Smith & Nephew, Johnson & Johnson, and Medipost. Received August 11, 2014; accepted September 8, 2014. autograft, especially in high-level athletes and high- 5-9 Address correspondence to Rachel M. Frank, M.D., Rush University Med- demand patients. Outcomes after ACLR with BTPB ical Center, 1611 West Harrison Street, Ste 201, Chicago, IL 60612, U.S.A. autografts are encouraging, with excellent subjective E-mail: [email protected] and objective outcomes, high return-to-play rates, and Ó 2015 by the Arthroscopy Association of North America low overall failure rates.9-14 Complications after ACLR 0749-8063/14687/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.09.004 with BPTB autografts are uncommon but can include Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 2 (February), 2015: pp 329-338 329 330 R. M. FRANK ET AL. patellar fractures, patellar tendon rupture, patellar guidelines.20 Before conducting the search, a systematic subluxation, diminished extensor mechanism function, review registration was completed on August 12, 2013 and anterior knee pain.15-19 using the PROSPERO International prospective register The surgical technique for ACLR with BTPB a auto- of systematic reviews (registration number graft has been previously described7,8 and involves CRD42013005357).21 Two independent reviewers harvesting the central third of the ipsilateral patellar (R.M.F., R.M.) completed the search, which was per- tendon with bone plugs from the patella and tibia. After formed on August 13, 2013. The following databases incision through the skin and subcutaneous tissue, the were used: Medline (PubMed), CINAHL (Cumulative peritenon surrounding the patellar tendon is incised, Index to Nursing and Allied Health Literature), and allowing full exposure of the patellar tendon, followed Cochrane Central Register of Controlled Trials. The by harvest of the central third of the tendon. At the following terms were searched: “anterior cruciate liga- conclusion of the procedure, closure techniques are ment,”“patellar tendon defect,” and “randomized.” The variable and can include closing both the patellar tendon electronic search citation algorithm used was: acl[All and peritenon defects, closing either the patellar tendon Fields] AND (“patellar ligament”[MeSH Terms] OR or peritenon defect alone, or leaving both defects unre- (“patellar”[All Fields] AND “ligament”[All Fields]) OR paired. Currently, there is no consensus regarding the “patellar ligament”[All Fields] OR (“patellar”[All Fields] standard of care for management of the patellar tendon AND “tendon”[All Fields]) OR “patellar tendon”[All defect after ACLR with a BPTB autograft. Fields]) AND defect[All Fields] AND closure[All Fields]. The purpose of this study was to review the published Inclusion criteria included English-language, Level I literature on ACLR with a BPTB autograft with patellar and Level II randomized controlled trials comparing tendon defect closure versus no closure after surgery. patellar tendon defect closure to no closure with a We hypothesized that there would be no significant minimum of a 6-month follow-up after ACLR with a difference in clinical outcomes between patients un- BPTB autograft. Exclusion criteria included noneEnglish dergoing patellar tendon defect closure compared with language studies, basic science or imaging studies, novel those without closure. technique studies, scientific meeting abstracts/proceedings, and systematic reviews/meta-analyses. Levels of Evi- Methods dence I and II were deemed inclusive (per the Oxford We performed a systematic review of multiple Centre for Evidence-Based Medicine used by the medical databases using Preferred Reporting Items for American version of the Journal of Bone and Joint Sur- Systematic Reviews and Meta-Analyses (PRISMA) gery22 and Arthroscopy). All references within included Fig 1. Systematic review search algo- rithm using Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines within Medline database. After application of all exclusion criteria, 4 studies were identified for final analysis. Table 1. Summary of Study Demographic Information Average Number of Number Number of Number Number Follow-up Patients No. of Level of of Average Age Male With With Duration, Available Right Graft Author Year Journal Evidence Patients Age, yr Range, yr Patients PT Closed PT Open mo for Follow-up (%) Knees Used Surgical Technique Adriani 1995 KSSTA I 61 26 17-52 40 (66%) 36 (59%) 25 (41%) 6 61 (100%) 33 BPTB Arthroscopically assisted ACLR et al.25 autograft with inside-out technique Side-to-side repair of tendon defect in 25 Tendon left open; peritenon closed in 36 Kohn 1994 KSSTA I 50 29 19-37 31 (62%) 25 (50%) 25 (50%) 30 40 (80%) NA BPTB Two-incision arthroscopically et al.17 autograft assisted ACLR with notchplasty CLOSURE OF THE PATELLAR TENDON DEFECT IN ACLR Similar tunnel and screw sizes within groups Closed (group I): patellar defect packed with reamed bone Æ additional cancellous bone from tibial head; peritenon closed with running No. 2-0 Vicryl sutures Open (group II): patellar defect loosely covered with gel foam, peritenon left open Cerullo 1995 KSSTA I 50 23.5 17-34 43 (86%) 25 (50%) 25 (50%) 6 40 (80%) NA BPTB Closed group: 3 full-thickness et al.26 autograft simple interrupted No. 0 Vicryl sutures, followed by peritenon closure in same way if possible Open group: peritenon closure in same way if possible Brandsson 1998 KSSTA I 60 28 17-48 40 (67%) 29 (48%) 31 (52%) 24 50 (83%) NA BPTB Two-incision arthroscopically et al.24 autograft assisted outside-in technique; meniscal pathologic process addressed as needed; notchplasty in 100%; paratenon closed in all with interrupted sutures Closed group: patellar tendon defect closed, patellar bone grafted Open group: neither of above Average 55.25 26.63 16.50
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