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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DISCUSSION

When considering ACL reconstruction, determination of the graft type is one of the most important decisions to be made, perhaps second only to the decision to perform the surgery itself. Recent multiple, well-designed studies comparing differences among grafts have shown equivalent long-term results, leading to the lack of a universally accepted gold standard.^5-7 Thus, both autograft and allograft ACL surgeries are routinely performed in the United States. Surgeons typically take into account factors such as patient age and physical demands, along with their own preferences and/or experience, when considering graft selection. A paucity of research concerning existing pathological conditions that could also influence preoperative decision-making has been observed; most reports consist only of expert opinion.^11-13 Our goal is to determine the prevalence of several conditions that could potentially affect an autograft harvested from the extensor mechanism.

This study revealed an overall prevalence of 10.1% of existing extensor mechanism pathology in patients sustaining an acute ACL tear and presenting for ACL reconstruction. Only 1 (0.5%) showed evidence of a multipartite patella, which is below the reported prevalence of 0.2% to 6%.¹⁴The presence of a multipartite patella could potentially have the most deleterious effect on a qTB autograft. Although not as commonly used as HS, QT, or pBTB autografts, some surgeons prefer a qTB autograft because of its increased surface area, bony fixation, and reported decreased donor site pain.¹⁵ A multipartite patella could complicate harvesting, disrupt the bone block, or lead to an unstable segment of the patella. These effects are of great concern since the most common location of a bipartite patella is superior-lateral and the quadriceps tendon has been shown to asymmetrically insert laterally.¹⁶ While these potential adverse effects have not been specifically studied, the availability of comparable options makes the use of a qTB autograft in the setting of a bipartite patella questionable.

Four patients (2%) revealed evidence of ossicles within the inferior patellar tendon consistent with unresolved Osgood-Schlatter’s disease. Osgood-Schlatter’s disease has been reported to occur in up to 21% of active adolescents and is historically considered a self-resolving process.¹⁷ Recent papers have reported persistent symptoms in up to 10% of patients, with a small percentage experiencing persistent free ossicles within their patella tendon on MRI.^18,19 The presence of such ossicles raises concern about the integrity of the patellar tendon and questions its use as an autograft when present. This concern was published in a report with the surgeon opting to utilize an alternate graft due to the presence of unresolved Osgood-Schlatter’s disease.¹³

Fifteen patients (7.6%) demonstrated radiographic evidence suggestive of patella tendinopathy based on the thickness of the proximal patella tendon. Patella tendinopathy is the most common tendinopathy in skeletally mature athletes and one of the most common athletic injuries of the knee, with a reported career prevalence of 22%.²⁰ It is described as an overuse injury due to the cumulative effect of micro trauma without an adequate healing interval. While it remains a clinical diagnosis, patellar tendinopathy often shows radiographic findings best assessed on sagittal MRIs. In general, the normal patella tendon appears as a homogenous low-intensity structure and is of uniform thickness. A tendon affected with tendinopathy typically demonstrates a focal increase in signal on T2-weighted sequences just distal to the tendon origin on the inferior pole of the patella. In addition, the patella tendon will usually demonstrate thickening, primarily in the proximal medial and posterior fibers. Patella marrow changes and indistinct tendon margins can also be present. The sensitivity and specificity of diagnosing patellar tendinopathy on MRI are 78% and 86%, respectively.²⁰ We derived our criteria for MRI evidence suggestive of patella tendinopathy from studies by El-Khoury and colleagues,⁸ Johnson and colleagues,⁹ and Popp and colleagues.¹⁰ In a 1992 study, El-Khoury and colleagues⁸ compared MRI findings between a group of patients with a clinical diagnosis of patella tendonitis and a control group without knee complaints. The authors found that the average proximal patella tendon diameter in the control group was 3.7 mm while the average proximal patella tendon diameter in the patella tendinopathy group was 10.9 mm; no patella tendons in the control group were >7 mm.⁸ In a 1996 study, Johnson and colleagues⁹ determined that the most reliable MRI finding for patients with patellar tendonitis is significant thickening of the proximal patella tendon seen on the sagittal view. The average thickness in symptomatic patients was 8.5 mm (range, 5-15 mm). The average thickness in the control group was 5.5 mm. None of the control patients had a proximal tendon thickness >7 mm.⁹ Finally, Popp and colleagues¹⁰ reviewed the MRI of 11 knees of patients who underwent surgical débridement of chronic patellar tendonitis and reported an average proximal patella tendon thickness of 12 mm (range, 9-16 mm). We therefore used a proximal patella tendon thickness of >7 mm on the sagittal view as a radiographic finding suggestive of patella tendinopathy. No data regarding symptoms of anterior knee pain were available among our patients. Histological studies of patients with patella tendonitis have shown evidence of chronic inflammation, fibrinoid necrosis, mucoid degeneration, and synovial proliferation within the patella tendon insertion.²¹ Although no controlled data showing that patella tendons with a history of tendonitis are more prone to failure than those without such history when used as an autograft for ACL reconstruction, the idea of utilizing a diseased tendon for a graft is not ideal. Some surgeons question their patients regarding a history of anterior knee pain and will not use a pBTB autograft in a patient with a positive history.²²

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