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Dr. Prodromos ACL Blog August 2017

Dr. Prodromos ACL Blog August 2017


It is well established that Non-Steroidal Anti-inflammatory Drugs (NSAIDs) such as ibuprofen (motrin, advil), naproxen (aleve), aspirin, celebrex, diclofenac, and meloxicam interfere with the healing of ligaments, bones, tendons and other connective tissue. For this reason Orthopaedic Surgeons are cautious in their use after reconstructive surgery and in other applications - although there are few clinical studies showing the effect of NSAIDs on outcomes. However, a recent paper entitled Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction from the US Navy published in the American Journal of Sportsmedicine found a significant correlation with the use of NSAIDs and an increased rate of revision, i.e. failure, after ACL reconstruction. This held true for both so-called COX-1 NSAIDs, the vast majority available, and also COX-2 NSAIDs which include Celebrex and Meloxicam. The authors write “Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors.” This reinforces the conclusion found in one of the few other papers to look at this topic The effect of ketorolac on anteroposterior knee laxity after anterior cruciate ligament reconstruction. where it was found that “The use of ketorolac during bone-patellar tendon autograft ACL reconstruction was associated with increased AP laxity at 6 weeks postoperatively.”

It is also well established that NSAIDs have a high incidence of severe side effects including GI bleeds, kidney failure and liver damage. For example, an iconic New England Journal of Medicine paper estimated that in excess of 15,000 deaths occur annually in the US alone from NSAID use.

CONCLUSION: In my clinical practice I strictly avoid the regular use of these drugs peri-operatively for ACL reconstruction and for 18 months afterward while ligamentization of the tendon graft is occurring. We use gabapentin 900-1200 mg immediately pre-operatively as a form of multi-modal anesthesia, and oral hydrocodone-acetominophen post-operatively. This regimen has provided satisfactory pain control without NSAID use and without the use of nerve blocks for my population of exclusively hamstring autograft ACL reconstruction patients. While the peri-operative use of NSAIDs is certainly within the standard of care for physicians who choose to use them, this most recent paper reinforces our decision to avoid them. Our one exception is the judicious use of peri-operative low dose (81mg) aspirin for DVT prophylaxis which we feel is justified on a risk-benefit basis.

51. Am J Sports Med. 2016 Aug 12. pii: 0363546516660062. [Epub ahead of print]. Pullen WM(1), Bryant B(2), Gaskill T(3), Sicignano N(4), Evans AM(4), DeMaio M(1).

BACKGROUND: Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature.

PURPOSE: To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non-active-duty beneficiaries.

STUDY DESIGN: Descriptive epidemiology study.

METHODS: Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure-related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort.

RESULTS: The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non-active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest.

CONCLUSION: In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.

Twenty-Year Outcome of a Longitudinal Prospective Evaluation of Isolated Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon or Hamstring Autograft.

Thompson SM(1), Salmon LJ(2), Waller A(1), Linklater J(3), Roe JP(1), Pinczewski LA(4).

BACKGROUND: Long-term prospective studies of isolated endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors.

PURPOSE: This study aimed to compare the outcomes of isolated ACL reconstruction using the patellar tendon (PT) autograft and the hamstring (HT) autograft in 180 patients over 20 years.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: A total of 180 participants undergoing isolated ACL reconstruction between 1993 and 1994 were prospectively recruited. Evaluation was performed at 1, 2, 5, 7, 10, 15, and 20 years after surgery and included the International Knee Documentation Committee (IKDC) knee ligament evaluation with radiographic evaluation, KT-1000 arthrometer side-to-side difference, and subjective scores.

RESULTS: Over 20 years, there were 16 patients (18%) and 9 patients (10%) with an ACL graft rupture in the HT and PT groups, respectively (P = .13). ACL graft rupture was associated with male sex (odds ratio [OR], 3.9; P = .007), nonideal tunnel position (OR, 3.6; P = .019), and age <18 years at the time of surgery (OR, 4.6; P = .003). The odds of a contralateral ACL rupture were increased in patients with the PT graft compared with patients with the HT graft (OR, 2.2; P = .02) and those aged <18 years at the time of surgery (OR, 3.4; P = .001). The mean IKDC scores at 20-year follow-up were 86 and 89 for the PT and HT groups, respectively (P = .18). At 20 years, 53% and 57% of the PT and HT groups participated in strenuous or very strenuous activities (P = .55), kneeling pain was present in 63% and 20% of the PT and HT groups (P = .018), and radiographic osteoarthritic change was found in 61% and 41% of the PT and HT groups (P = .008), respectively.

CONCLUSION: Compared with patients who received the HT graft, patients who received the PT graft had significantly worse outcomes with regard to radiologically detectable osteoarthritis, kneeling pain, and contralateral ACL injury. At 20-year follow-up, both HT and PT autografts continued to provide good subjective outcomes and objective stability. However, further ACL injury is common, particularly in male individuals, younger patients, and those with tunnel malposition.

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