New research from Henry Ford Hospital in Detroit, Michigan, suggests that patients undergoing anterior cruciate ligament reconstruction using a hamstring tendon autograft experience less pain during the early postoperative period than those who receive a bone-patellar tendon-bone autograft. The study was published in the December issue of Orthopaedic Journal of Sports Medicine.
ACL Reconstruction Hurts MORE Than Tendon Allograft
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Secondary
Both hamstring tendon autografts (HS) and bone-patellar tendon-bone (BTB) autografts are popular options for anterior cruciate ligament (ACL) reconstruction. While most research is inconclusive on whether one autograft is better than the other, this new study indicates that the type of autograft you choose could affect pain levels after surgery.
Kelechi R. Okoroha, M.D., an orthopedic surgery resident at Henry Ford Hospital, and colleagues conducted a cohort study of 70 patients who underwent ACL reconstruction using either a BTB or HS autograft. Postoperative pain was measured for up to three days after surgery using a visual analog scale. Secondary outcomes also tracked included opioid consumption, hours slept, breakthrough pain and patient satisfaction with pain management.
According to the study, 47 patients underwent ACL reconstruction with a BTB autograft while 23 patients received a HS autograft. Patients in the BTB group were slightly younger than those in the HS group with the mean age 19. 7 years versus 33.4 years, respectively.
The results of the study revealed that patients treated with a BTB autograft experienced more pain overall and more breakthrough pain (day 1, 76% vs. 43% [p = .009]; day 2, 64% vs 35% [p = .003]) in the early postoperative period than those treated with a HS autograft.
When surveyed about their overall satisfaction with pain management, BTB patients reported being less satisfied on the day of surgery and the subsequent two days. There was however no difference in sleep patterns or in opioid consumption between the two groups.
Okoroha told OTW that the difference in pain level between the two grafts is most likely because BTB grafting involves extensive dissection in the anterior knee and more bony cuts whereas HS grafting requires only soft tissue resection.
He emphasized that he and his colleagues were not suggesting that HS autografts are superior to BTB autografts. Instead they recommend that physicians make their patients aware of the differences in pain level along with the other pros and cons for each grafting choice and that physicians continue to search for better ways to alleviate early postoperative pain.
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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