Long-term results of
a randomized study on anterior cruciate ligament reconstruction with or without
a synthetic degradable augmentation device to support the autograft

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.

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.

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?
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?

by: Jacob Crow
by: Lisa Chinn and Jeffrey Driban

Peterson L, Eklund U, Engström B, Forssblad M, Saartok T, & Valentin A (2013). Long-term results of a randomized study on anterior cruciate ligament reconstruction with or without a synthetic degradable augmentation device to support the autograft. Knee Surgery, Sports Traumatology, Arthroscopy PMID: 23996068