Graft Choices and Outcomes in Anterior Cruciate Ligament Reconstruction:
A Guide for Physical Therapy Students
Reid Medlin, SPT
During my first clinical rotation at an outpatient orthopedic clinic, I worked with several patients who were either planning on having or had recently had anterior cruciate ligament (ACL) reconstructive surgery. My limited clinical exposure to this population, in addition to not yet having had coursework on the lower extremities, left me at a bit of a disadvantage when answering patients’ questions regarding the types of grafts available and their associated outcomes. Even though I have numerous friends and family members who have had ACL reconstructive surgery, I had never given much thought to stability or functional outcome measures associated with different grafts. After reviewing the material presented to our class on the ACL and reconstructive surgery, I felt like there was somewhat of a “gap” in the knowledge on specific outcomes for autograft choices. One or two statements were provided regarding bone-patellar tendon-bone autografts as being the “gold standard,” but this left room for many questions. Having the current evidence-based knowledge on specific outcomes associated with autograft types will allow student physical therapists to be able to better answer the questions their patients often ask during pre-reconstructive therapy. In addition, this knowledge would allow student therapists to tailor rehabilitation for specific types of athletes and/or patients who use one graft over another. The need for improved student education regarding the advantages and disadvantages associated with different types of ACL grafts formed the foundation for my Capstone project.
Overview and Purpose
The number of individuals sustaining ACL injuries has increased over the past 20 years, mainly due to increased awareness and detection of these injuries, as well as the growing number of adolescents involved in sports at an early age1,2,3. ACL injury rates begin to increase in females at 12-13 years of age and in males at 14-15 years of age4. ACL injuries are most prevalent in individuals aged 15-45, with the risk rising to 1 in 17505. According to the High School Sports-Related Injury Surveillance Study, ACL injuries accounted for 25.6% of all knee-related injuries in the United States6. ACL injuries and/or reconstructions put these athletes at risk for limited future sport participation and for developing osteoarthritis (OA) later in life7-10. Researchers have been trying to identify the ideal graft for patients that reproduces the anatomy and biomechanics of the native ligament, allows for rapid and complete healing and incorporation, and causes low or no morbidity of harvest. Most of the current research is conflicting and states that this ideal graft does not currently exist, making it difficult for patients and therapists to draw conclusions as to the more superior graft choice11. The purpose of this project is to provide DPT students with comprehensive information on the anatomy and biomechanics of the ACL, common mechanisms of injury, clinical tests for ACL insufficiency, descriptions of the common graft options for reconstructive surgery as well as their association outcomes, and a general progression for rehabilitation following ACL reconstruction.
Because of my limited knowledge and clinical experience with different ACL grafts and outcomes, I developed the foundation for this project based on academic work I completed during our Topics in Health Promotion and Wellness course as well as our Evidence Based Practice II course. In the Health Promotion and Wellness course, I designed a program proposal to target and prevent ACL injuries in adolescent soccer players in order to help combat the staggering number of adults who develop OA in North Carolina. The information acquired from this proposal lead me to develop a PICO question in our EBP II course investigating whether patellar tendon or hamstring tendon autografts provided more knee stability in active young adults with an ACL rupture. From this question, a Critically Appraised Topic was created on this issue. Both of these projects were valuable in helping to develop my Capstone presentation. A fellow classmate, Laura Rapp, developed her Critically Appraised Topic on the long-term outcomes associated with allografts and autografts following ACL reconstructive surgery (see her Capstone website here). After speaking with her, I discovered we both agreed that a joint Capstone presentation regarding outcomes and advantages/disadvantages associated with different types of ACL grafts would be beneficial for current DPT students.
- The first product of my Capstone project is an evidence table of recently published research outlining the outcomes associated with patellar tendon versus hamstring tendon autografts following ACL reconstructive surgery. This was an easy way to organize most of my evidence and helped me in developing my VoiceThread presentation.
- The main product of my Capstone project is a VoiceThread presentation designed with the goal to better prepare current DPT students going out on clinical rotations on questions regarding the ACL and outcomes associated with different grafts. Creating this VoiceThread with Laura Rapp allowed for a more comprehensive presentation, with more in-depth information on both allograft and autograft options.
It is my goal to return to UNC next year with Laura to present a version of this Capstone to the MSK II class, as they are taught information regarding the ACL during this course. Because the students in this course had already gone on clinical rotations before the completion of this Capstone, the VoiceThread presentation was the best way to provide this information to them at this time.
While the information in my Capstone presentation most directly relates to material taught to students in the MSK II course, students in any year of the program can benefit from viewing the presentation. I have created a brief survey for anyone to complete after viewing the material.
Please click here to provide valuable feedback for my Capstone VoiceThread presentation!
From conception to completion, the process of creating this Capstone project has taught me a lot about myself. I started out with deadlines that I created for myself and quickly realized that life can get in the way! I now know that I am capable of being flexible and realistic with deadlines that I set for myself and have learned that I am able to deal with conflicts better than I thought. I am happy that I have these skills, as they will prove to be valuable as I become more of an autonomous physical therapist. Working with a fellow classmate on the creation of the VoiceThread challenged and strengthened my communication skills, reiterating the importance of utilizing effective communication as a physical therapist. Interestingly, after reading so much research on how inconclusive the studies are that aim to identify a superior ACL graft, I find myself becoming interested in potentially getting involved in this area of research in the future. Helping to conduct research would allow me to not only give back to the profession, but possibly advance it as well.
I want to give a huge thank you to my committee members Jon Hacke and Tara Lane for their valuable advice and feedback in developing the presentation. I also want to thank my capstone advisor Mike Gross for his indispensible knowledge and experience that helped me create my Capstone project. Lastly, I want to thank my friend and “co-creator” Laura Rapp for not only contributing half of the work and time that went into making the VoiceThread, but for being a great team player and putting up with me during its creation!
- Micheli LJ, Metzl JD, Di Canzio J, Zurakowski D. Anterior cruciate ligament reconstructive surgery in adolescent soccer and basketball players. Clin J Sport Med. 1999;9(3):138-141.
- Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med. 2006;16(6):500-513.
- Comstock RD, Collins CL, Corlette JD, Fletcher EN; Center for Injury Research and Policy of The Research Institute at Nationwide Children’s Hospital. National high-school sports-related injury surveillance study, United States, 2007-2008 school year; 2011-2012 school year. http://www.nationwidechildrens.org/cirp-rio-study-reports. Accessed September 11, 2014.
- Dharamsi, A., & LaBella, C. Prevention of ACL Injuries in Adolescent Female Athletes. Contemporary Pediatrics. 2014. Accessed September 11, 2014, from http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/prevention-acl-injuries-adolescent-female-athletes.
- Anterior Cruciate Ligament Injury (ACL). Department of Orthopaedic Surgery. Retrieved October 16, 2014, from http://orthosurg.ucsf.edu/patient-care/divisions/sports-medicine/conditions/knee/anterior-cruciate-ligament-injury-acl/.
- Comstock RD, Collins CL, Currie DW. National High School Sports-Related Injury Surveillance Study: 2012-2013 School Year. High School RIO. 2013. Retrieved October 18, 2014 from http://www.ucdenver.edu/academics/colleges/PublicHealth/ research/ResearchProjects /piper/projects/RIO/Pages/Study-Reports.aspx.
- Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med. 2010 Aug;26(3):355-69. PubMed PMID: 20699159; PubMed Central PMCID: PMC2920533.
- Centers for Disease Control and Prevention. Osteoarthritis. 2014. Assessed September 11, 2014, from http://www.cdc.gov/arthritis/basics/osteoarthritis.htm.
- PubMed Health. Osteoarthritis. 2013. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0001460/.
- Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007 Oct;35(10):1756-69. PubMed PMID: 17761605.
- Prohaska DJ, Griffin JR, Haarner CD. Comparison of Graft Choices for ACL Surgery. PDF. Accessed online at www.drprohaska.com/patienthandouts/ACL% 20Graft%20Comparison.pdf.