Original Research

Epidemiology of Existing Extensor Mechanism Pathology in Primary Anterior Cruciate Ligament Ruptures in an Active-Duty Population

Publish date: August 31, 2018

References

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Anterior cruciate ligament (ACL) reconstruction is an extremely common procedure; in fact, an estimated 60,000 to 175,000 ACL reconstructions are performed annually in the United States.^1,2 One of the most widely debated aspects of ACL reconstruction is the choice of graft. Grafts are broadly categorized into allografts and autografts. The autograft selections for ACL reconstruction include patellar bone-tendon-bone (pBTB), combined semitendinosus and gracilis hamstrings (HS), free quadriceps tendon (QT)without accompanying bone block, and quadriceps tendon-bone (qTB). Allograft choices predominantly include pBTB and HS, as well as the tibialis anterior and Achilles tendons. The pBTB autograft is traditionally considered the reference standard for ACL reconstruction.³ Recent advances in allograft processing, along with improved fixation techniques and devices, have improved results following the use of soft-tissue autografts and both bony and soft tissue allografts.⁴ Thus, the optimal graft choice for ACL reconstruction has become controversial in light of several studies demonstrating no significant, long-term difference in clinical and/or functional outcomes based on graft selection.^5-7

Given the lack of a clear gold standard in graft selection, multiple patient factors, such as age, activity demands, and patient preference, should be taken into account when considering the choice of graft. In addition, intrinsic factors that could potentially weaken an autograft should be considered. Several extensor mechanism pathological findings that are easily visualized on either plain radiographs or magnetic resonance imaging (MRI) could potentially affect graft selection. Findings such as a multipartite patella, free ossicles about the tibial tuberosity consistent with Osgood-Schlatter’s disease, and proximal patella tendon thickening suggestive of patellar tendinopathy are easily identifiable on preoperative imaging and could exert adverse effects on pBTB, QT, and qTB autografts. The purpose of this study is to identify the prevalence of these pre-existing conditions in active-duty military patients presenting with acute ACL tears.

METHODS

A retrospective review was conducted on all active-duty patients who underwent primary ACL reconstruction at our institution from July 2006 to February 2009. A systematic review of all plain radiographs and MRIs was performed on a calibrated picture archiving and communication system workstation. Imaging review was conducted by 2 of the authors. Pertinent findings included a multipartite patella, free ossicles within the patella tendon, and hypertrophy of the proximal aspect of the patella tendon. Assessment for multipartite patella and unresolved Osgood-Schlatter's disease was made using plain radiographs with MRI for confirmation. Measurements of the patella tendon were performed on the short tau inversion recovery and T2-weighted sagittal MRI images at the point of maximal tendon width. A width of ≥7 mm was considered suggestive of patella tendinopathy based on prior studies.^8-10 The prevalence of each finding was then determined based on the total number of patients.

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