Peterson L, Eklund U, Engstrom B, Forssblad M, Saartok T, Valentin A. Knee Surgery Sports Traumatology Arthroscopy. 2013 August 18
Take Home Message: There is evidence that an augmentation device to support an anterior cruciate ligament autograft benefits athlete’s rehabilitation in the short-term, however, this study reported no differences between knees with and without an augmentation device in long-term subjective outcomes.
We commonly see reconstruction of the anterior cruciate ligament (ACL) in athletics. During surgery, a surgeon may add an augmentation device to support the bone-patellar tendon-bone (BPTB) autograft during early healing and rehabilitation period (within 9 months of surgery). Multiple studies have found that augmentation devices are effective in providing stability within initial rehabilitation and healing, however, there have been limited studies assessing the long-term effects of augmentation devices. Therefore, Peterson and colleagues compared the outcome of ACL reconstruction with BPTB autograft, with and without a poly(urethane urea) augmentation device, at 1-, 4-, and 12-years post-surgery. The study included 201 patients with diagnosed ACL injury. The patients randomly received either a BPTB autograft with a synthetic augmentation device (96 patients) or without augmentation (105 patients). The authors conducted pre- and postoperative examinations at 1 and 4 years, which included several outcomes: knee ligament laxity, Lachman’s test, pivot shift, Tegner scoring system for physical activity level, International Knee Documentation Committee (IKDC) for subjective assessments of knee function, and Knee Injury Osteoarthritis Outcome Score (KOOS). There was an additional long-term follow-up (12 years post-surgery) that included questionnaires (Tegner activity level, KOOS scores in pain, activities of daily living) to determine knee-specific health. The authors found that although the augmentation group consistently scored better than the non-augmentation group, there were no significant differences at any time periods. Compared to immediately pre-surgery both groups had improved knee-related quality of life, function in sports and recreational activities, function in activities of daily living, and pain after 12 years post-ACL reconstruction. The researchers also found more complications in the augmentation device group compared to the non-augmentation device group, such as augmentations coming loose due to insufficient screw fixation to the femur.
As a clinician there are many situations in which coaches and athletes desire short-term outcomes. There is evidence that an augmentation device for an ACL autograft benefits athletes in the short-term. However, this study reported no differences between groups for subjective outcomes in the long term and those who received the augmentation had a higher risk for complications. I think this is something that is easily overlooked by clinicians that are constantly focused on the immediate impact for patients. Patient outcomes should be a driving factor in implementing goals for rehabilitation; the patient outcomes should be considered in the short term (return to play) as well as the long term (long term daily living). This study should cause us to step back and re-assess the use of augmentation devices by considering if the possible short-term benefits are sufficient to justify their use; particularly if they increase the risk of complications and in the long-term they don’t add benefit.
Questions for Discussion: As a healthcare professional, how often do you consider long-term consequences of treatment and interventions? As a clinician have you ever had an athlete with an augmentation device? Have you observed any secondary complications of the augmentation device? If you had to give advice for a patient going into surgery about the use of augmentation device what would you suggest? How did you come up with your suggestion?
Written by: Jacob Crow
Reviewed by: Lisa Chinn and Jeffrey Driban