Abstract
Objectives
To establish the influence of the type of surgical technique, competitive level, type of sport and the time before returning to competition on the reinjury rate after anterior cruciate ligament (ACL) surgery.
Methods
The authors followed-up 540 competitive sportspeople who had undergone ACL surgery via patellar or hamstring tendon autograft (HTA) techniques in 2003 and 2004. The sportspeople (all of whom had competed at a regional or higher level) were asked to fill out a questionnaire during their fourth postoperative year.
Results
The 298 respondees (reply rate: 55.1%) had the same characteristics as the initial (operated) population. The reinjury rates after HTA and patellar tendon autograft (PTA) were 12.7 and 6.1%, respectively. There was no statistically significant difference between these two values ( P = 0.14). Age and gender were not correlated with the frequency of reinjury. The reinjury rate rose slightly with increasing competitive level (regional level: 8.1%; national level: 10.4%; international level: 12.5%) but these differences were not statistically significant. Soccer had the highest reinjury rate (20.8%). Regardless of the surgical technique, sportspeople returning to competition within seven months of surgery had a greater risk of reinjury than those returning after this time point (15.3 versus 5.2%, P = 0.014). The risk dropped from 13.9 to 2.6% ( P = 0.047) for PTA and from 16.6 to 7.6% ( P = 0.2) for HTA. Of the four reinjuries in sportspeople returning to competition with the first six months postoperative, three occurred within one month of resumption.
Conclusion
Post-HTA reinjury rates are higher than post-PTA rates but the difference is not statistically significant. For sportspeople at a regional or higher level, the time interval before the return to competition has an influence on the risk of reinjury.
Résumé
Objectifs
Déterminer l’influence du type de chirurgie, du niveau sportif, du type de sport et des délais de reprise de la compétition sur la fréquence des récidives.
Patients et méthode
Les auteurs ont suivi par questionnaire 540 sportifs ayant bénéficié d’une chirurgie du ligament croisé antérieur de type tendon rotulien (OTR) ou aux ischiojambiers (DIDT) en 2003 et 2004. Tous sont compétiteurs, de niveau minimum régional, et ont reçu un questionnaire pendant la quatrième année postopératoire.
Résultats
Les 298 sportifs ayant répondu ont les mêmes caractéristiques que ceux de la population initiale. Le taux de réponse est de 55,1 %. La fréquence des récidives après DIDT est de 12,7 %, tandis que la fréquence des récidives pour les OTR est de 6,1 %, sans différence significative ( p = 0,14). L’âge et le sexe n’influencent pas la fréquence des récidives. La fréquence des récidives est en légère augmentation avec le niveau, sans différence significative : régional 8,1 %, national 10,4 %, et international 12,5 %. Le football est le sport ayant le taux de récidives le plus élevé (20,8 %). Toutes chirurgies confondues, les joueurs reprenant avant le septième mois ont un risque plus élevé de récidives (15,3 contre 5,2 %) que lorsqu’ils reprennent après le septième mois ( p = 0,014). Ce risque évolue pour l’OTR de 13,9 à 2,6 % ( p = 0,047) et pour le DIDT de 16,6 à 7,6 % ( p = 0,2). Sur les quatre récidives survenues chez le sportif ayant repris avant six mois, trois ont eu lieu dans le mois de la reprise.
Conclusion
Les taux de récidives après DIDT ne sont pas différents statistiquement de ceux après OTR, malgré un risque de récidives légèrement plus élevé. Pour le sportif compétiteur minimum de niveau régional, le délai de reprise influence le risque de récidives.
1
English version
There is little evidence in the literature of true differences in performance between the patellar tendon autograft (PTA) and hamstring tendon autograft (HTA) surgical techniques used in anterior cruciate ligament (ACL) reconstruction . The PTA has been linked to more frequent anterior pain , whereas the HTA tends to result in greater residual knee laxity . This lack of a clear difference means that surgeons choose one or other of the techniques as a function of their own experience.
Few studies have analyzed the reinjury rate as a function of the surgical technique and even fewer have focused on the influence of the type of sport on reinjury. This is surprising, since the goal of this type of surgery is to enable a return to competition.
Hence, we decided to study a population of competitive sportspeople (at a regional or higher level) and determine the influence of the type of ACL surgery on the return to competition and the reinjury rate. We also sought to identify risk factors for reinjury by looking at the type of sport and the time interval between surgery and the return to competition.
1.1
Patients and methods
1.1.1
Methods
We systematically monitored all the sportspeople having attended our rehabilitation centre after ACL surgery. The data were entered into a computerised database to enable follow-up of clinical, surgical and sporting parameters. After including the sportspeople (playing at a regional or higher level) having undergone PTA or HTA surgery for ACL reconstruction in 2003 and 2004, we sent them a questionnaire concerning the return to competition during their fourth postoperative year (mean: 3.5 years; range 36 to 48 months).
Only two surgical techniques had been concerned in our study subjects: PTA and HTA. The PTA technique involves transplantation of the patellar tendon and creation of a femoral tunnel and a tibial tunnel. The HTA technique requires two hamstring tendons (the semitendinosus and the gracilis) folded back over each other to perform a transplant with a femoral and a tibial tunnel. The operations had been performed by 48 surgeons throughout France, many of whom were specialists in orthopaedic surgery of the ACL; eight of the latter accounted for 40% of the operations.
The rehabilitation programmes performed during the sportspeople’s stay in our centre and recommended on discharge were based on the postoperative recovery of joint amplitudes (0/0/120°), quadriceps contractions against gravity and gait without the use of technical aids in the three to six weeks following surgery. Depending on the surgeon’s recommendations, a brace was worn for three to six weeks. Cardiovascular training (on a cycle ergometer, stepper and/or rowing machine) was implemented progressively. Crawl-style swimming was also initiated during this period. Resumption of running was authorized at around three or four months post-op, depending on the surgeon’s recommendations. Resumption of the person’s original sport was determined by the surgeon.
The questionnaires were sent out in two batches (at the end of 2006 and the end of 2007, respectively). Of the 540 recipients, 298 replied (55.1%). The population of respondees did not differ significantly from the initial (operated) population in terms of the surgical technique, the competitive level, the sport practised, age and gender.
We excluded sportspeople with a history of contralateral or repeat ruptures, osteotomy, chondroplasty, associated complex ligament damage and ligamentoplasty with extra-articular reinforcement.
Data on the age, gender, sport and type of surgery were obtained from the patient database. The questionnaire focused on repeat ruptures, whether or not the sportsperson had returned to competition, the time interval between surgery and the return to competition and the time required to return to the sportsperson’s previous competitive level.
1.1.2
Statistical analysis
For qualitative variables, we used a two-tailed Chi-square test to compare subgroups. If the sample size was too small, we used a Student Test to compare quantitative variables. If the sample sizes in the groups were not equivalent, we applied a Mann-Whitney test. All analyses were performed by a statistician using Graph-Pad PRISM ® 2007 software (version 5.00) and STATA software (version 8). The significance threshold was set to P < 0.05. Data missing from the questionnaires were not considered in the statistical analysis.
1.1.3
Material
We have analyzed the replies from 298 sportspeople (160 having undergone an HTA and 138 having undergone a PTA [ Table 1 ]). The gender ratio was similar for each technique (HTA: 122 men and 38 women; PTA: 112 men and 26 women). The HTA and PTA groups had a mean age of 26 and 25, respectively.
| Reinjury-free group | ||||
|---|---|---|---|---|
| Gender | Number | Age (min–max) | Level | |
| PTA + HTA | 59F 213M | 272 | 26.0 ± 7.68 (16–53) | 146R, 87N, 15 In, 24? |
| HTA | 33F 109M | 142 | 26 ± 8,3 (16–53) | 71R, 46N, 9 In, 16? |
| PTA | 26F 104M | 130 | 25 ± 6.96 (16–52) | 75R, 41N, 6 In, 8? |
| Reinjured group | Time to reinjury (months) | ||||
|---|---|---|---|---|---|
| PTA + HTA | 5F 21M | 26 (8.7%) | 24 ± 5.99 (16–43) | 13R, 10N, 2 In, 1? | |
| HTA | 5F 13M | 18 (12.7%) | 24 ± 5.92 (16–43) | 9R, 6N, 2 In, 1? | 22 ± 13.6 (6–44) |
| PTA | 0F 8M | 8 (6.1%) | 25 ± 6.43 (18–33) | 4R, 4N, 0 In, 0? | 21.8 ± 15.4 (6–48) |
| Total | ||||
|---|---|---|---|---|
| HTA | 38F 122M | 160 | 26 ± 8.1 (16–53) | 80R, 52N, 11In, 17? |
| PTA | 26F 112M | 138 | 25 ± 6.91 (16–52) | 79R, 45N, 6 In, 8? |
The most frequently practiced sport ( Table 2 ) was rugby (26.1%), followed by soccer (17.7%), skiing (10.7%) and handball (8%). There was no significant difference between the HTA and PTA groups in terms of the sport practised.
| Disciplines | Number of subjects | ||
|---|---|---|---|
| HTA | PTA | Total (%) | |
| Rugby | 37 | 41 | 78 (26.1) |
| Soccer | 28 | 25 | 53 (17.7) |
| Skiing | 23 | 9 | 32 (10.7) |
| Handball | 11 | 13 | 24 (8) |
| Basketball | 8 | 9 | 17 (5.7) |
| Judo | 4 | 5 | 9 (3) |
| Tennis | 3 | 6 | 9 (3) |
| Volley | 5 | 1 | 6 (2) |
| Motorcycling | 5 | 2 | 7 (2.3) |
| Pelota | 2 | 5 | 7 (2.3) |
| Athletics | 3 | 2 | 5 (1.6) |
| Gymnastics | 3 | 2 | 5 (1.6) |
| Swimming | 5 | 0 | 5 (1.6) |
| Rock climbing/snowboard | 3 (× 2) | 0 | 6 |
| Diving | 1 | 2 | 3 (1) |
| Canoeing/kayaking | 2 | 0 | 2 (0.6) |
| Golf/hockey/ice hockey/sailing | 1 (× 4) | 1 (× 4) | 8 |
| Karate/Taekwondo | 0 | 2 (× 2) | 4 |
| Wrestling | 1 | 0 | 1 |
| Rowing/running/bull-leaping/cycling/dancing | 1 (× 5) | 0 | 5 |
| American football/petanque/waterskiing/surfing | 0 | 1 (× 4) | 4 |
| Others | 4 | 4 | 8 |
| Total | 160 | 138 | 298 |
A total of 273 sportspeople had stated their competitive level ( Table 1 ; regional level: 58.6%; national level: 35.1%; international level: 6.2%).
The HTA and PTA groups were considered to be comparable because there were no significant intergroup differences in terms of gender, age, competitive level or the sport practised.
1.2
Results
1.2.1
The repeat rupture rate as a function of the surgical technique used
We observed 26 repeat ruptures (8.7%) in the 298 sportspeople (12.7% in the HTA group and 6.1% in the PTA group; P = 0.14, ns) ( Table 1 ).
1.2.2
The time to reinjury as a function of the surgical technique used
The mean time to a repeat rupture (i.e. reinjury) was 22 months for the HTA group and 21.8 months for the PTA group ( Table 1 ). The intergroup difference was not statistically significant.
1.2.3
The influence of age on repeat rupture
Age did not have a statistically significant relationship with the frequency of repeat rupture. The mean age of the reinjured sportspeople was 24, versus 26 for those not reinjured ( Table 1 ). Again, this intergroup difference was not statistically significant.
1.2.4
The influence of gender on repeat rupture
Gender did not have a statistically significant relationship with the repeat rupture rate (7.8% in women and 8.9% in men). For HTA, the reinjury rate was 13.1% for women and 10.6% in men. For PTA, the reinjury rate was 7.1% in men, with no cases of reinjury in women ( Table 3 ). Again, the intergroup difference was not significant.
| Reinjured women | Reinjury-free women | Reinjured men | Reinjury-free men | Total | |
|---|---|---|---|---|---|
| HTA | 5 | 33 | 13 | 109 | 160 |
| PTA | 0 | 26 | 8 | 104 | 138 |
| Total | 5 | 59 | 21 | 213 | 298 |
1.2.5
The influence of competitive level on repeat rupture
For the two surgical techniques taken together, we noted a non-significant trend towards an increase in the reinjury rate with increasing competitive level ( Table 4 ). The rate was 8.1% for the regional-level sportspeople, 10.4% for the national-level sportspeople and 12.5% for the internationals.
| Number of repeat ruptures (%) | ||||
|---|---|---|---|---|
| HTA | PTA | PTA + HTA | ||
| Level | Regional | 9 out of 80 (11.2%) | 4 out of 80 (5%) | 13 out of 160 (8.1%) |
| National | 6 out of 52 (11.5%) | 4 out of 44 (9.1%) | 10 out of 96 (10.4%) | |
| International | 2 out of 11 (18.2%) | 0 out of 6 | 2 out of 16 (12.5%) | |
1.2.6
The influence of the type of sport on repeat rupture
According to the French ARPEGE classification, sports can be classified according to the following categories: “pivoting with contact”, “pivoting with no contact”, “weight-bearing with no pivoting” and “non-weight-bearing”. The sports with pivoting accounted for 96% of the reinjuries (i.e. 25 out of 26 cases). Nineteen of the cases (73%) involved “pivoting with contact” sports.
For the two surgical techniques taken together, the risk of reinjury was slightly higher for “pivoting with contact” sports (9.9%) than for “pivoting with no contact” sports (8.5%) and “no pivoting” sports (3.5%). These differences were not statistically significant ( Table 5 ). This risk was slightly higher for the HTA group than for the PTA group in both “pivoting with contact” or “pivoting with no contact” sports (13% for HTA versus 7% for PTA in sports “pivoting with contact” and 11.6% for HTA versus 3.7% for PTA in sports of “pivoting with no contact”).
| Number of subjects | |||||||
|---|---|---|---|---|---|---|---|
| Reinjury PTA + HTA (%) | Total PTA + HTA | Reinjury HTA | Total HTA | Reinjury PTA | Total PTA | ||
| ARPEGE classification | With pivoting and contact | 19 (9.9%) | 191 | 12 (13%) | 91 | 7 (7%) | 100 |
| With pivoting, no contact | 6 (8.5%) | 70 | 5 (11.6%) | 43 | 1 (3.7%) | 27 | |
| Weight-bearing, no pivoting | 0 | 17 | 0 | 12 | 0 | 5 | |
| Not weight-bearing | 1 (8.3%) | 12 | 1 (10%) | 10 | 0 | 2 | |
The highest risk of reinjury occurred in soccer (20.8%); there was a significant difference ( P = 0.03) versus rugby players, for whom the reinjury rate was 6.4%. This could be explained by the type of sport and a tendency for the soccer players to return to competition sooner (8.1 months) than the rugby players did (10.6 months; P = 0.25, ns). For skiers, the reinjury rate was 12.5% ( Table 6 ).
| Gender of the reinjured sportspeople | Competitive level of the reinjured sportspeople | Mean age of the reinjured sportspeople | Mean time before the return to competition (months) | PTA + HTA (% reinjury) | HTA (% reinjury) | PTA (% reinjury) | |
|---|---|---|---|---|---|---|---|
| Rugby | 0F, 5M | Reg: 1 Nat: 4 Int: 0 | 25 | 10.6 | 5 out of 78 (6.4%) | 2 out of 37 (5.4%) | 3 out of 41 (7.3%) |
| Soccer | 0F, 11M | Reg: 9 Nat: 2 Int: 0 | 22 | 8.1 | 11 out of 53 (20.8%) | 7 out of 28 (25%) | 4 out of 32 (16%) |
| Ski | 2F, 2M | Reg: 2 Nat: 0 Int: 1 | 29 | 7.5 | 4 out of 32 (12.5%) | 3 out of 23 (13%) | 1 out of 9 (11.1%) |
For injuries suffered in “pivoting with contact” sports, surgeons used the HTA technique significantly less often (58%) than PTA (74%) ( P = 0.01). There was no significant influence of the surgical technique on the reinjury rate for any of the sports ( Table 6 ): 7.3 and 5.4% for PTA and HTA for rugby, 16 and 25% for soccer and 11.1 and 13% for skiing.
1.2.7
The mechanisms of reinjury
Pivoting and contact trauma were the most frequent mechanisms of reinjury for both surgical techniques (pivoting: 25% for PTA and 33.3% for HTA; contact: 25% for PTA and 27.7% for HTA) ( Table 7 ).
| Number of subjects | ||||
|---|---|---|---|---|
| Reinjury after HTA | Reinjury after PTA | Total number of reinjuries (%) | ||
| Mechanism of reinjury | Contact | 5 (27.7%) | 2 (25%) | 7 (26.9%) |
| Pivot | 6 (33.3%) | 2 (25%) | 8 (30.8%) | |
| Hyperextension | 1 (5.5%) | 1 (12.5%) | 2 (7.7%) | |
| Fall | 2 (11%) | 0 | 2 (7.7%) | |
| Not known | 4 (22.2%) | 3 (37.5%) | 7 (26.9%) | |
| Total | 18 | 8 | 26 | |
Even though 11 of the 26 reinjured sportspeople had the impression that they suffered from greater knee laxity after the operation, only one patient (having undergone PTA) considered that this was directly due to an anomaly of the first ligamentoplasty. The other patients stated that the repeat rupture was due to external causes.
1.2.8
The influence of changing to another sport on the reinjury rate
After the initial ACL rupture, 11 patients practicing “pivoting with contact” sports were advised to take up less risky sports: “pivoting with no contact” sports in four cases, “weight-bearing with no pivoting” sports in three cases and “non-weight-bearing” in four cases. None of these patients experienced repeat rupture, although the small sample size prevented us from testing for a statistically significant difference in the reinjury rate between the sportspeople who had returned to their original “pivoting with contact” sport (reinjury: 19 out of 191) and those who had changed to another sport (reinjury: 0 out of 11).
1.2.9
The influence of the time interval before returning to competition on the reinjury rate
The sportspeople having returned to competition within the first seven months post-op had a higher risk of repeat ruptures (15.3%) than those returning after that time point (5.2%; P = 0.014; Table 8 ). This difference was also statistically significant for the PTA group, with a reinjury rate of 13.9% when returning to competition in the first seven months, whereas this risk decreased to 2.6% after the seventh month ( P = 0.047). In contrast, the difference was less marked for the HTA group, with a reinjury rate of 16.6% for resumption within the first seven months and 7.6% after that time ( P = 0.2, ns).
| Number of subjects | |||||||
|---|---|---|---|---|---|---|---|
| Number of reinjuries PTA + HTA (%) | Total PTA + HTA returning to competition during the period | Number of reinjuries HTA (%) | Total. HTA | Number of reinjuries PTA (%) | Total. PTA | ||
| Time before the return to competition | [3;7 months] | 14 (15.3%) | 91 | 8 (16.6%) | 48 | 6 (13.9%) | 43 |
| After the 7th month | 8 (5.2%) | 154 | 6 (7.6%) | 78 | 2 (2.6%) | 76 | |
For the 72 sportspeople having returned to competition within six months of surgery, there were four reinjuries (three of which occurred within one month of resumption).
1.2.10
The return to competition
In all, 292 of the sportspeople replied to this question: 251 (86%) had returned to competition within 3.5 years of surgery (89.6% for PTA and 82.8% for HTA; P = 0.13, ns) ( Table 9 ).
| Returned to competition? | Time before returning to competition (months) | |||||
|---|---|---|---|---|---|---|
| Number Yes (%) | Number No | Statistics P | With repeat rupture (mean, SD, min–max) | Without repeat rupture (mean, SD, min–max) | Statistics P | |
| HTA | 130 (82.8%) | 27 | 0.13 | 8.07 ± 2.1 (6–12) | 8.8 ± 3.2 (4–24) | 0.1 |
| PTA | 121 (89.6%) | 14 | 8.5 ± 6.4 (3–24) | 9.4 ± 4.1 (3–24) | 0.1 | |
| PTA + HTA | 251 (85.9%) | 41 | 8.2 ± 4.1 (3–24) | 9.1 ± 3.6 (3–24) | 0.35 | |
In terms of a return to competition within the first year post-op (not including the 12th month), the proportion was slightly higher for HTA (66.2%) than for PTA (64.6%) (ns). When the 13th month was included, the “return to competition rate” was 80.5% for HTA and 80.4% for PTA.
The time interval between surgery and the return to competition was slightly shorter in the repeat rupture group of sportspeople (8.2 months) than in the injury-free group (9.1 months; P = 0.35, ns). For the reinjured sportspeople, the HTA group returned to competition more quickly (8.8 months) than the PTA group (9.4 months; P = 0.1, ns).
1.2.11
Return to the sportsperson’s former competitive level
Of the 283 sportspeople having replied to this question, 186 (65.7%) considered that they had returned to their pre-injury competitive level after 3.5 years or less ( Table 10 ). There was no significant difference ( P = 0.4) between the PTA (65.1%) and HTA (66.2%) groups. The proportion of sportspeople having returned to their former level within one year (at 11 months) was slightly higher for HTA (39.6%) than for PTA (31%; P = 0.14, ns). After 13 months, the proportion of sportspeople having returned to their pre-injury level was 53.9% in the HTA group and 46% in the PTA group.
| Returned to previous competitive level? | Time interval for returning to previous competitive level (months) | ||||
|---|---|---|---|---|---|
| Number Yes (%) | Number No | Statistics P | Mean ± SD (min–max) | Statistics P | |
| HTA | 102 (66.2%) | 52 | 0.4 | 10.8 ± 4.2 (3–24) | NS |
| PTA | 84 (65.1%) | 45 | 12.1 ± 5.6 (5–36) | ||
The sportspeople having undergone an HTA returned to their former level after an average of 10.8 months, versus 12.1 months for the PTA group. This intergroup difference was not statistically significant.
1.3
Discussion
We observed an overall repeat rupture rate of 8.7% (12.7% for the HTA group versus 6.1% for the PTA group, with no significant intergroup difference). Our results are in agreement with most of the comparative studies in the literature, which have reported a higher reinjury rate for HTA and the lack of a statistically significant difference between HTA and PTA. Wagner reported reinjury rates of 5.6% for HTA and 4.2% for PTA, with no significant intergroup difference. Keays et al. observed reinjury rates of 6.4% for HTA and 0% for PTA. Salmon et al. recorded values of 7% for HTA and 6% for PTA, again with no significant difference. Pinczewski et al. found reinjury rates of 13.3% for HTA and 7.7% for PTA ( P = 0.24, ns), whereas Barett et al. found 23% for HTA vs 8% for PTA ( P = 0.1). The only statistically significant difference was reported by Freedman et al. , with 1.9% for PTA versus 4.9% for HTA. In a meta-analysis, Biau et al. failed to find a significant difference, with 3.4% for PTA and 4.1% for HTA. There are frequent literature reports of the fragility of the HTA (relative to the PTA) and a certain degree of weakness of the fixation mechanisms used, when compared with the “bone–tendon” system for the PTA; this translates into greater laxity for HTA, as noted by several studies . Furthermore, Pinczewski et al. have demonstrated a relationship between knee laxity and reinjury. However, improvements in HTA surgical techniques (notably four-strand plasty and stronger attachment systems [endobuttons, screws with staples, etc.] ) have helped to decrease the residual laxity. Roe et al. and Wagner et al. even reported recently that HTA resulted in less laxity. Furthermore, anatomic, four-tunnel surgery heralds the future of the HTA technique, with improved stability and better graft positioning when performed with computer guidance.
Even though Shelbourne et al. suggested that age had an influence on reinjury in a group of patients from different sports, we found that age is not a risk factor for repeat ACL rupture in a population at the same competitive level.
In contrast to studies on the initial ligament damage (in which women suffer from ACL rupture more frequently than men ), we found that gender had no influence on the repeat rupture rate (with 7.8% in women and 8.9% in men). This lack of a gender effect on reinjury has also been confirmed in the literature .
In the present study, sports with pivoting accounted for 96% of the reinjuries; 73% of these were “pivoting with contact” sports, which reflects well the incidence of this type of sport on the mechanisms of rupture. We also found a significantly higher repeat rupture rate ( P = 0.03) for soccer (20.8%) than for rugby (6.4%). In addition to the type of sport (indicating a higher risk of reinjury in soccer players), another explanation is possible, since soccer players returned to competition sooner than the rugby players did (8.1 versus 10.6 months; ns). The literature reports rarely mention the reinjury rates for each sport . Salmon et al. found that soccer and rugby are the most affected sports in Australia, whereas Shelbourne et al. mentioned basketball in Florida; it is likely that the data reflect the fact that sporting practices differ from one country to another. In the present work, it is interesting to note that the surgeons preferred the PTA in “pivoting with contact” sports (74 versus 58% for HTA). However, we did not observe a significant difference between HTA and PTA in terms of the reinjury rates in each sport. Hence, it seems reasonable to consider both techniques in all cases (regardless of the sport). However, this observation must be tempered by the fact that our per-sport analysis had small sample sizes – especially for soccer, in which the reinjury rates were high (16% for PTA and 25% for HTA).
Our results concerning the mechanisms of autograft injury were similar to those reported for initial ACL rupture . In fact, the most frequent reinjury mechanism involves pivoting and contact trauma for both PTA and HTA, with no significant difference between the two groups. According to Salmon et al. , participation in sports with sudden changes of direction, pivoting or jumping is a clear risk factor for reinjury after a return to competition. This risk is amplified for contact sports.
There was a slight increase in the repeat rupture with increasing competitive level, although this increase was not statistically significant. This same trend has been found for the initial ACL rupture . According to Bjordal et al. , the risk of initial rupture is mainly linked to the number of hours of sport and the competitive level.
In the present study, sportspeople returning to competition within the first seven months post-op had a significantly higher risk of repeat ruptures (15.3%) than those returning after this period (5.2%). Of the four reinjuries in the 72 sportspeople having returned to competition with the first six months post-op, three occurred with one month of resumption. Salmon et al. reported on the time interval before returning to competition and its relationship with repeat rupture. He stated that the risk of reinjury is higher during the first 12 months post-op. After this time point, the risk falls to a value which is equivalent to the rate of rupture of the contralateral ACL. Salmon et al. suggested that after a year, the autograft has matured and the muscle function has adapted itself to most activities. Thus, there are two contrasting positions: one protectionist and the other more aggressive. Whereas Salmon et al. remained cautious in terms of the return to competition, Shelbourne et al. found much the same reinjury rates for sportspeople returning to competition before six months vs after six months. Unfortunately, the latter study did not provide detailed information on the sports practiced, the competitive/leisure status or the competitive level. Indeed, in the latter work, 82% of the under-18s played competitively, whereas this was the case for only 37% of the 18–25 age class. The under-18s who returned to sport the soonest (after 4.6 months, on average) had a reinjury rate of 8.7%, whereas the rate for the 18–25 year-olds (who resumed later, after an average of 5.5 months) was 2.6%. It would have been interesting to see an analysis of the return to sport for populations which were comparable in terms of competitive level and for more varied periods of time (e.g. four, five or seven months, instead of six months only). Beynnon et al. also presented results in favour of accelerated rehabilitation, with no difference in laxity between ten patients in an accelerated post-PTA rehabilitation programme and 12 patients in a non-accelerated programme. However, the low number of participants decreased the study’s statistical power. In contrast, Fujimoto et al. considered that overly rapid resumption of running significantly destabilized HTA reconstructions. Likewise, Heijne and Werner reported an increase in laxity after open kinetic chain quadriceps exercises four weeks after the HTA procedure. The fragility mentioned in the literature was also observed in our study, with a 16.6% reinjury rate for resumption before the seventh month post-HTA and just 7.6% for resumption after the seventh month. Even though this difference was not statistically significant for HTA, it was for the PTA group, with a risk of 13.9% for resumption before the seventh month and 2.6% for resumption after the seventh month ( P = 0.047).
In the present study, the proportion of sportspeople returning to competition within 3.5 years (on average) of surgery was very high, for both HTA (82.8%) and PTA (89.6%). Even though the value for PTA was higher, there was no significant intergroup difference. Our results agree with the literature data: 81% for both PTA and HTA in the study by Smith et al. , 95% for PTA and 88% for HTA in the study by O’Neill , 70% for PTA and 51% for HTA in the study by Corry et al. , 65% for PTA and 79% for HTA in the study by Aglietti et al. and, lastly, 54% for PTA and 52% for HTA in the study by Feller and Webster . In the present study, we did not find a significant difference between PTA (65.1%) and HTA (66.2%) in terms of a successful return to the sportsperson’s former competitive level. Although our criterion was subjective (being related to the sportsperson’s judgment), our results are in line with the literature. Thus, Biau et al. reported that 67% of an HTA group and 76% of a PTA group returned to their sport at the same competitive level. Lee et al. reported a value of 62.2% five years after HTA-based surgery. In sportspeople competing at a regional or higher level, Savalli et al. found a significantly lower value after one year for PTA (53%) than for HTA (60%). In contrast, the rates converged (and even inversed slightly) towards 18–24 months, with 73% for PTA and 72% for HTA. This suggests slower clinical maturation for PTAs. Our results were similar, in as much as the injury-free post-HTA sportspeople tended to return to competition sooner (after 8.8 months, on average) than the corresponding PTA group (9.4 months, on average). However, this difference was not statistically significant. Our results were nevertheless similar to those found in literature. Nakayama et al. considered that a return to competition is possible after an average of 8.1 months, whereas Laboute et al. quoted 9.06 month and Rousseau et al. reported 10.1 months. In contrast, our results were very different from those reported by Shelbourne et al. , who found that 71.8% of the under-18 population had returned to full activity within six months of surgery (i.e. a mean time interval of 4.6 ± 1.9 months). However, our population of competitive sportspeople was very different to that studied by Shelbourne et al. , in which only 35% of the 18–25 age class were competitors. Our population including only four under-18 sportspeople, whereas Shelbourne’s contained at least 37%. Our study also included very few women (21%), whereas Shelbourne’s study featured a balanced gender ratio. We mainly studied soccer and rugby players, whereas Shelbourne’s population mainly featured basketball players (52%). However, one can note that the male population in Shelbourne’s study (most of whom were competitive sportsmen) were quite similar to our population. Shelbourne reported a reinjury rate of 10.6% for this subgroup, which is close to our value of 13.9% for reinjury in sportspeople returning to competition before the seventh month. In any case, Shelbourne’s value is far higher than our value of 2.6% for the post-PTA sportspeople who returned to competition after the seventh month. Hence, one should probably remain cautious in terms of the time interval before returning to competition. However, one can also interpret our results and those of Shelbourne differently by considering that more intensive rehabilitation can help accelerate the recovery of muscle strength and thus decrease the risk of reinjury when returning to competition soon after surgery.
As part of the systematic follow-up of our rehabilitation programmes, our study was performed by sending a questionnaire to the patients an average of 3.5 years after ligamentoplasty. Our methodology was very similar to that used by Wright et al. and Shelbourne et al. . However, our questionnaire response rate was lower (55.1 versus 86% for Wright et al. and 78% for Shelbourne ). One explanation for this difference is that we did not chase up our patients by telephone, whereas the other two authors did. However, the results of our study are optimized by the fact that the respondee population did not differ significantly from the operated population in terms of the gender ratio, age, type of surgery, sport and competitive level. Hence, our highly homogeneous population and the long time interval since surgery (3.5 years, on average) enabled us to obtain statistically pertinent results. Moreover, this was a large, homogeneous series of sportspeople competing at a regional or higher level; this has rarely been the case in studies in the literature, which often feature leisure sportspeople. We were also able to investigate the impact of the sport practiced and the competitive level on the reinjury rate. We also detailed the risk of reinjury on returning to competition before the seventh month post-op. We believe that full resumption of training within six months of surgery (depending on the extent of muscle recovery) is required if one is expecting to return to competition after the seventh month. In contrast, we were not able to assess the degree of functional and muscle-related recovery at the time of the return to competition, which could explain the occurrence of repeat ruptures soon after resumption. In the meantime, accelerated post-PTA rehabilitation could be justified for high-level, competitive sportspeople with particular requirements for more rapid resumption (despite a higher risk of reinjury ) by checking the extent of muscle-related recovery. In view of our present findings and until further assessments have been performed, we believe that caution is advisable for other sportspeople.
1.4
Conclusion
The post-HTA reinjury rate was slightly higher than the post-PTA rate, although this difference did not achieve statistical significance. Age and gender did not influence the reinjury rate. Soccer was the sport with the greater risk of reinjury. For the competitive sportsperson playing at a regional or higher level, the time interval before returning to competition influences the risk of reinjury, which rises from 15.3% before the seventh month to 5.2% afterwards.
Conflict of interest statement
None.
2
Version française
Peu de différences ont pu être véritablement mises en évidence entre les techniques chirurgicales de reconstruction par le tendon rotulien (OTR) et celles par les ischiojambiers (DIDT) . L’OTR présente des douleurs antérieures plus fréquentes , tandis que le DIDT évolue vers une laxité résiduelle plus importante . Si bien qu’actuellement, chacune des techniques est utilisée en fonction de l’expérience et des choix du chirurgien.
Cependant, peu d’études ont analysé la fréquence des récidives en fonction des techniques chirurgicales et encore moins se sont intéressées à l’impact de la pratique sportive sur la fréquence de ces récidives, alors que l’objectif d’une telle chirurgie est souvent la reprise du sport.
Nous avons cherché à connaître chez une population de sportifs compétiteurs, au minimum de niveau régional, l’influence du type de chirurgies sur la reprise du sport et sur la fréquence des récidives. Nous avons également recherché des facteurs de risque de récidives à travers le type de pratique sportive et les délais de reprise de la compétition.
2.1
Patients et méthode
2.1.1
Méthode
Nous avons suivi systématiquement par questionnaire les sportifs ayant eu des chirurgies du ligament croisé antérieur (LCA) et qui ont bénéficié d’un séjour ponctuel dans notre centre de rééducation. Les données ont été collectées sur une base informatique pour un suivi clinique, chirurgical et sportif. Après avoir inclus les sportifs de niveau minimum régional ayant bénéficié d’une chirurgie du LCA de type OTR ou DIDT en 2003 et 2004, nous leur avons adressé un questionnaire d’évaluation de la reprise sportive durant la quatrième année postopératoire, avec des extrêmes allant de 36 à 48 mois, soit une moyenne de 3,5 ans.
Le geste chirurgical n’a concerné que deux techniques, celle au tendon rotulien et celle aux ischiojambiers. La technique avec le tendon rotulien (OTR) a été réalisée avec un transplant au tendon rotulien, un tunnel fémoral et un tunnel tibial. La technique avec les ischiojambiers (DIDT) a nécessité deux ischiojambiers (semi-tendineux et gracilis), repliés sur eux-mêmes pour réaliser un transplant, avec seulement un tunnel fémoral et un tunnel tibial. Le nombre de chirurgiens sur le territoire national était de 48, souvent spécialisés dans la chirurgie orthopédique du LCA, notamment pour huit d’entre eux (soit 40 % des interventions).
Les programmes de rééducation appliqués durant le séjour dans le centre et conseillés à la sortie ont été basés sur une récupération postopératoire des amplitudes articulaires (0/0/120°), de la contraction contre pesanteur du quadriceps et de la marche sans aide technique dans les trois à six semaines postopératoires. Une attelle a été gardée trois à six semaines suivant l’avis chirurgical. Un travail cardiovasculaire sur bicyclette, stepper, rameur a été progressivement mis en place. La natation type crawl a été commencée durant cette période. La reprise de la course a été effective environ autour du troisième ou quatrième mois en fonction de l’avis chirurgical. L’autorisation de la reprise de l’activité d’origine a été déterminée par le chirurgien.
Les questionnaires ont été respectivement envoyés à la fin de l’année 2006 et 2007. Sur les 540 qui ont reçu le questionnaire, 298 ont répondu. Le taux de réponses a été de 55,1 %. La population ayant reçu le questionnaire n’est pas différente statistiquement de celle qui a répondu au questionnaire en termes de chirurgie, de niveau sportif, de sport pratiqué, d’âge et de sexe.
Ont été exclus de l’étude, les sportifs ayant des antécédents de ruptures controlatérales ou de ruptures itératives, les ostéotomies, les chondroplasties, les lésions ligamentaires complexes associées et les ligamentoplasties complétées d’un renforcement externe.
Les données concernant l’âge, le sexe, ainsi que les informations sportives et chirurgicales proviennent de la base d’inclusion informatique des patients. Le questionnaire s’est intéressé à la rupture itérative, la reprise du sport, les délais de reprise de la compétition, ainsi qu’à la reprise au niveau antérieur estimée par le sportif et son délai.
2.1.2
Analyse statistique
Nous avons utilisé le Chi 2 test pour mettre en évidence des différences statistiques concernant les variables qualitatives ( two-tailed ). Lors de la présence de groupes de nombre suffisant, nous avons utilisé le Student Test pour comparer les variables quantitatives. En cas d’effectifs inégaux ou insuffisants, nous avons utilisé le Mann-Whitney Test. Les calculs ont été réalisés par informatique avec une statisticienne sur Graph-Pad PRISM ® 2007 version 5.00 et STATA version 8. Le seuil de significativité a été considéré à partir de p < 0.05. Les items non renseignés dans les dossiers n’ont pas été retenus pour les calculs statistiques.
2.1.3
Matériel
Nous avons analysé les réponses de 298 sportifs, soit de 160 DIDT et 138 OTR ( Tableau 1 ). Notre population était répartie de façon harmonieuse entre les deux sexes, quelle que soit la chirurgie avec une dominante masculine (DIDT : 122 hommes, 38 femmes et OTR : 112 hommes, 26 femmes). L’âge moyen était de 26 ans pour le groupe DIDT et de 25 ans pour le groupe OTR.
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