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Abstract & Commentary
Synopsis: From analysis of postoperative results, it appears that bone-patellar tendon-bone autografts for ACL reconstructions are a reasonable graft option for women.
Source: Ferrari JD, et al. Arthroscopy. 2001;17(6):588-596.
Ferrari and colleagues retrospectively reviewed the results of bone-patellar tendon-bone autografts done from 1987 to 1994 in 200 patients, comparing the results in men (137 patients) with the results in women (63 patients). Ferrari et al state that these results have been previously published, but prior publications did not attempt to compare men to women. The same surgeon performed all procedures, and although postoperative technique and rehabilitation schemes evolved during this period, the same protocols were used for procedures done on both men and women during the same time. No mention is made in the article as to whether the percent of reconstructions done in men vs. women have varied during the time period.
All 200 included in this study were evaluated by physical examination, KT 1000 testing, functional testing, radiographic evaluation, and outcome assessments including the Tegner, Lysholm, modified HSS, and Cincinnati rating scales, as well as the SF36 health survey, and a self-administered assessment questionnaire. Ferrari et al report that postoperatively no differences were noted in Lachman, anterior drawer, pivot shift, or functional testing in either group. However, males did have slightly lower KT 1000 scores (maximal manual side-to-side differences of 0.76 mm in men vs 1.73 mm in women), but there were no differences in the percentage of patients with a side-to-side difference greater than 5 mm.
Women did score higher than men on SF36 testing for Role Physical and Body Pain General Health categories, but Ferrari et al had no preinjury scores for comparison and therefore used gender-matched controls. No marked differences were found in the other outcome assessments.
Therefore, Ferrari et al argue that since there are no significant differences between males and females reconstructed with bone-patellar tendon-bone autograft on examination of physical findings, arthrometric analysis, or outcome assessments, this graft selection is as appropriate for women as for men.
COMMENT BY LETHA Y. GRIFFIN, MD, PhD
With increasing numbers of women playing competitive sports, and with the incidence of ACL injuries greater for women than men in many sports requiring pivoting and jumping (e.g., soccer and basketball), the question arises as to whether surgical procedures used traditionally to treat ACL injuries in men are also appropriate for women. Some have argued that since women have been reported to have an increased incidence of anterior knee pain, graft options other than bone-patellar tendon-bone autografts should be considered in this population.
Although Ferrari et al have nicely shown no major outcome differences in women compared with men following ACL reconstruction using bone-patellar tendon-bone autograft, they nonetheless do report a fairly substantial percentage of anterior knee symptoms following reconstruction in all patients. Thirty-eight percent of men and 29% of women had the inability to kneel longer than 10 minutes when evaluated 36-79 months following their reconstructions. Surprisingly, only 14% of women had pain on ascending or descending steps compared with 18% of men and only 3% of women compared with 6% of men had crepitance greater than grade 1. Unfortunately, since this is a retrospective study, no data are available on the preoperative assessment of Q-angle or patellofemoral symptoms in either men or women.
Studies such as this, which thoroughly evaluate physical findings, arthrometric data and outcome studies following ACL reconstruction in men and women are helpful for all of us to review before counseling patients regarding the risks and benefits of various graft choices for ACL reconstruction.