Overall Pearson product-moment correlations revealed a moderate relationship between IKDC Subjective Knee Evaluation and KOS-ADLS scores (r = 0.86, P < 0.0001) and a weaker relationship between IKDC Subjective Knee Evaluation and KOS global overall rating scores for activities of daily living (r = 0.78, P < 0.0001). A moderate relationship was also observed between IKDC Subjective Knee Evaluation and KOS-SAS scores (r = 0.82, P < 0.0001), and a weaker relationship was observed between IKDC Subjective Knee Evaluation and KOS global overall rating scores for sports activities (r = 0.72, P < 0.0001).
Only 21% (3/14) of the panelists at the Eighth Panther Sports Medicine Symposium reported using allograft tissues for ACL reconstruction (15). Regardless of whether an autograft or an allograft is used, the transplanted tissue will inevitably biodegrade and remodel, serving as a scaffold for the patient's own collagen to infiltrate. Shino et al. (39) reported that allograft tissues used for ACL reconstruction function similarly to autograft tissues at 2-10 yr after surgery. In a retrospective study of 79 patients at ≥ 2 yr after ACL reconstruction using either BPTB autografts (mean age = 28.7 yr) or BPTB allografts (mean age = 33.1 yr), both augmented with an illiotibial band tenodesis, Chang et al. (9) reported no significant group Lysholm score differences, although more allograft group patients had slight knee-flexion deficits and retropatellar pain. In a prospective nonrandomized study, Peterson et al. (30) compared patients who underwent ACL reconstruction using either a BPTB allograft (mean age = 28 yr) or a BPTB autograft (mean age = 25 yr) with follow-up visits at 3, 6, 12, 24, and 60 months after surgery, reporting no differences for pain, giving way, effusion, or laxity. In a prospective cohort study that observed patients for the initial 5 yr after surgery, Poehling et al. (31) reported similar outcomes when primary ACL reconstruction was performed using Achilles tendon allografts or BPTB autografts. Although patient ages were not reported, individuals with allografts had slightly greater anterior knee laxity that did not increase over time; less pain at 1 and 6 wk after surgery; better function at 1 wk, 3 months, and 1 yr after surgery; and superior activity levels at all time frames compared with patients who had received BPTB autografts (31). In a prospective nonrandomized study, Schepsis et al. (35) compared the outcomes of patients who underwent ACL reconstruction using either a quadrupled hamstring autograft (mean age = 26 yr) or an identically sized fresh-frozen or cryopreserved hamstring allograft (mean age = 31.5 yr). At an average of 29 months after surgery, they reported similar group Lysholm, Tegner, Subjective IKDC Knee Evaluation scores, and knee-laxity measurements (35). In a retrospective study at 10 yr after primary ACL reconstruction with nonboned Achilles, tibialis anterior, or tibialis posterior tendon allografts among 125 patients (mean age = 20.9 yr), using the IKDC Subjective Knee Evaluation, Nakata et al. (28) reported 27% normal, 73% near normal, and 0% abnormal or severely abnormal results. In a prospective nonrandomized study that used the IKDC Clinical Knee Examination guidelines to compare 36 patients who underwent ACL reconstruction using fresh-frozen BPTB allografts (mean age = 36 yr, mean 46 months after surgery) and 26 patients who underwent the same surgery but with BPTB autografts (mean age = 26 yr, mean 52 months after surgery), Kleipool et al. (24) reported normal or nearly normal results for 18 patients (70%) and a fair result for eight patients (30%) in the autograft group. In the allograft group, 30 patients (85%) had a normal or nearly normal knee, five (13%) had fair results, and one (2%) had a poor result (24). In a retrospective study, Siebold et al. (41) compared outcomes at a mean of 3 yr after ACL reconstruction among patients who had received either a fresh-frozen BPTB allograft (N = 183, mean age = 39.8 yr) or an Achilles tendon allograft (N = 42, mean age = 38.5 yr), reporting normal or nearly normal outcomes on the IKDC Clinical Knee Examination guidelines for 75.3% of patients who received a BPTB allograft and for 76.2% who received an Achilles tendon allograft. Significantly more patients who received a BPTB allograft reruptured their reconstructed ACL than subjects who had received an Achilles tendon allograft (10.4 vs 4.8%, P < 0.001) (41). In a retrospective study that used the KOS-ADLS and KOS-SAS surveys, Pantano et al. (29) reported high satisfaction levels at 3-yr follow-up among a group of 44 patients (mean age = 30 yr) with 75% (33/44) who had undergone ACL reconstruction (40 = primary, 4 = revision) with either Achilles tendon (N = 18) or BPTB (N = 26) allografts, suggesting that larger subject groups and longer postoperative follow-up times were needed to confirm their findings.
This study found no difference for self-reported outcomes between group 1 subjects at ≥ 5 yr (mean = 7.8 ± 2.1 yr) or group 2 subjects between 2 and 4 yr (mean = 2.8 ± 0.8 yr) after primary ACL reconstruction using allograft tissues for the IKDC Subjective Knee Evaluation and the KOS-ADLS. However, group 1 subjects displayed a significantly lower mean KOS-SAS score, suggesting that in addition to a generalized decrease in sports activity level and frequency after primary ACL reconstruction, at ≥ 5 yr after surgery, subject-perceived sports activity function is further decreased. Our results were comparable with previous reports after primary ACL reconstruction using autograft tissues (10,11,22,25,37). Based on our results and these previous reports, we suggest that regardless of graft type, during the initial 5 yr after primary ACL reconstruction, most patients decrease their activity level and frequency by at least one grade, particularly during sporting activities (10,22,37). Whether this represents part of the normal aging process, behavior modification to protect the surgically reconstructed knee, or a combination of both is currently unknown.
Patient self-reports of perceived function and activity-level capability are vital examination components that warrant careful consideration. Ultimately, surgical and rehabilitation success is only achieved if patients continue to participate in their desired activities of daily living, including vocational and sporting activities, at their preinjury level and frequency. This study found that self-reported patient outcomes after primary ACL reconstruction using cryopreserved allograft tissues were comparable with previous studies of self-reported outcomes for patients who underwent primary ACL reconstruction using autograft tissues. Clinical examination and functional performance tests are ongoing.
We thank the Fischer-Owen Orthopaedic Research Fund of Norton Healthcare, Louisville, KY for sponsoring this study.
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