Higher Incidence of Postoperative Complications in Patients with Simultaneous Patellar Tendon and Anterior Cruciate Ligament Ruptures Following Single Surgery: A Case Series and Literature Review

doi:10.21203/rs.3.rs-4875378/v1

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Higher Incidence of Postoperative Complications in Patients with Simultaneous Patellar Tendon and Anterior Cruciate Ligament Ruptures Following Single Surgery: A Case Series and Literature Review

https://doi.org/10.21203/rs.3.rs-4875378/v1

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Background

Patients with simultaneous ruptures of the patellar tendon (PT) and anterior cruciate ligament (ACL) underwent PT repair and ACL reconstruction in a single or staged surgery. However, due to the limited cases, the design of previous studies was mostly case report with varying conclusions regarding recommended surgical strategy selection, many researchers suggest selecting a surgical strategy based on the surgeon's and patient's preferences.

Methods

10 cases in local institution and 27 cases from 17 studies were included in this study. Demographic information, injury cause, surgical strategy, combined injuries, whether to return to (pre-injury level) sports, postoperative complications, Lysholm score and International Knee Documentation Committee (IKDC) score were identified retrospectively or reviewed from previous studies. The Fisher’s exact test was used to compare the incidence of postoperative complications between different surgery strategy groups, and liner logistic regression was used to analyze factors influencing postoperative knee function scores.

Results

15 patients (40.5%) underwent single surgery and 22 patients (59.5%) underwent staged surgery. Postoperative complications occurred in 5 (33.3%) and 0 patients after the single and staged surgery, respectively, with the former being significantly more frequent than the latter (P = 0.007). Linear regression of postoperative knee function scores showed that surgical strategy did not significantly affect postoperative Lysholm and IKDC scores (P = 0.294 and P = 0.270, respectively).

Conclusions

Patients with simultaneous ruptures of PT and ACL had a higher incidence of complications after single surgery than staged surgery. We recommend that patients with this type of injury undergo staged surgery to minimize complications if a quick return to sports is not desired.

simultaneous ruptures

patellar tendon (PT)

anterior cruciate ligament (ACL)

surgical strategy

complications

Simultaneous ruptures of the patellar tendon (PT) and anterior cruciate ligament (ACL) is a type of rare combined knee injury, involving the knee extensor mechanisms and intra-articular structures, with acute knee pain, swelling, instability and limited range of motion (ROM)[1–3]. Severe knee symptoms make positioning and ligament testing difficult, and concomitant meniscus and/or medial collateral ligament (MCL) injuries are often found on magnetic resonance imaging[3]. PT repair and ACL reconstruction are the commonly accepted treatments[4–6]. Although well-defined management approaches for isolated PT or ACL ruptures have been established, however, selecting single or staged surgery for simultaneous ruptures of both structures is still no consensus[3, 7–10].

The single surgery allows patients to return to sports more quickly, but may cause conflicts in rehabilitation[1, 11]. The fragility of the newly repaired PT and knee fixation limit neuromuscular and early strength training after ACL reconstruction, which increases the risk of knee stiffness[1, 3, 6]. The staged surgery is initiated by PT repair and rehabilitation until extensor function is restored, then followed by ACL reconstruction[4, 12]. This procedure aims to avoid the rehabilitation conflicts, but prolongs the patients’ recovery periods[3, 11]. Regarding postoperative outcomes, researchers have drawn different results and conclusions, for instance, some researchers did not observe any complications in patients who underwent single surgery[13–15]. Because the optimal treatment has not yet been defined and the damage is complex, many researchers suggest selecting a surgical strategy based on the surgeon's and patient's preferences[4, 14].

We noticed that most of the previous studies related to surgical strategy were single-center case report with a low level of evidence[5, 6, 15–17]. Furthermore, due to the limited cases, few researchers have compared the prognosis of different surgical strategies for this type of injury. On this basis, 10 patients with simultaneous ruptures of PT and ACL from local institutions were reported, and 27 patients reported in previous studies were reviewed. We compared, for the first time, the postoperative knee function scores, complications, and return to (pre-injury level) sports in patients who underwent different surgical strategies, and explored the factors that influence the function scores. The hypothesis of this study is that staged surgery can reduce the incidence of postoperative complications.

Patient Selection

This study is a retrospective case series and literature review. After approval by the Institutional Review Board, all patients with simultaneous ruptures of PT and ACL between January 1, 2010, and December 31, 2021 were reviewed from the surgical medical record database in Peking University Third Hospital. The knee injury type was identified through the key words “patellar tendon rupture”, “anterior cruciate ligament rupture”, “patellar tendon suture repair”, “anterior cruciate ligament reconstruction”. Meanwhile, English-language literature on simultaneous ruptures of PT and ACL up to 1 January 2023 was searched in the PubMed and Google Scholar databases. The search terms used were (anterior cruciate ligament or ACL) AND (patellar tendon or patellar ligament or PT) AND (rupture or injury or tear) AND (simultaneous or combined or concomitant). Read the abstract to confirm that the literature is related to the simultaneous ruptures, and that at least one patient with this disease was reported in detail. Included patients with simultaneous ruptures of PT and ACL occurred on ipsilateral side. Exclusion criteria were as follows: (1) with a history of prior ipsilateral PT or ACL injury; (2) with concomitant posterior cruciate ligament (PCL) rupture; (3) no single or complete staged surgery was used; (4) surgical techniques not involving PT repair or ACL reconstruction; (5) with a chronic PT rupture; (6) lack of postoperative follow-up evaluation.

10 patients in local institution and 27 patients from 17 studies met the criteria. In local patients, the data collected were as follows: demographic information (age, sex, body mass index [BMI]), injury cause, side, interval between injury and primary surgery, surgical strategy (Recording the interval between two operations for staged surgery) and combined injuries. Telephone follow-up surveys were conducted to obtained pre-injury and postoperative data. All patients’ data are collected with the informed consent. Follow-up evaluation included postoperative complications, whether to return to (pre-injury level) sports, time to return to sports (from the last surgery), reasons for failure to return to pre-injury level of sports, pre-injury and postoperative Tegner score. Local patients also completed postoperative Lysholm score and International Knee Documentation Committee (IKDC) score. Postoperative complications defined as infection, stiffness, patella fracture, arthritis, arthrofibrosis, graft failure and thrombotic events[7, 18–20]. Successful return to pre-injury sports levels depended on identical pre-injury and postoperative Tegner scores, and the affirmation to the question “Have you attempted the sports at the same level that you did before your knee injury?”. The above evaluation was conducted by an independent observer who did not participate in the surgical procedure. In the previous studies, the data of patients and various authors' opinions on selecting surgical strategy were reviewed. Most previously reported patients did not indicate BMI, time to return to sports, and pre-injury and postoperative Tegner score, and were therefore not counted in this study.

Surgical Techniques

The ruptured PT had transosseous repair, which consists of suturing the ruptured PT through a transosseous tunnel in the patella and/or tibial tuberosity with knots. The ruptured ACL was reconstructed, with autologous ipsilateral hamstring tendon preferred as a graft. Other concomitant injuries were treated with standard surgical techniques, depending on the severity of the injury: MCL injuries were treated non-operatively in grade I and II injuries and sutured in the first operation in grade III injuries; meniscus injuries were treated either non-operatively or with a meniscal repair. All surgical procedures were conducted by surgeons who specialized in the sports medicine department and have undergone identical surgical training. The selection of surgery strategy depended on surgeon's and patient's preferences.

Postoperative Protocol

The rehabilitation programs varied according to the different surgical strategies. Patients undergoing single surgery were placed in a knee immobilizer and ROM was restricted to 90 degrees until 6 weeks, as well as exercises for the quadriceps. Patients undergoing staged surgery had their knees immobilized, and received physical therapy to restore full knee flexion and improved knee strength after PT repair. Early ROM exercises were performed to gradually build strength and transition to specific activities after ACL reconstruction.

Statistical Methods

All statistical analyses were performed using SPSS V. 23.0 (IBM Corp, Armonk, New York, USA). Descriptive statistics were computed via mean, standard deviation and range for continuous quantitative data, and frequencies with percentages for categorical qualitative data. In addition, proportions of effective cases were provided due to missing records for certain indicators. Independent samples t-test and Mann-Whitney U test were used to compare continuous variables between groups. The Fisher’s exact test was used to compare categorical variables between groups. Liner logistic regression was used to analyze factors influencing postoperative knee function scores. Significance was set at P < 0.05.

37 patients were included in this study (Table 1). Each patient is detailed in the supplementary material. There were 35 (94.6%) males and 2 (5.4%) females with a mean age of 29.3 ± 9.7 (range 15–50) years. Average follow-up from last surgery was 2.5 ± 2.2 (range 0.5–11.4) years. The injured side was the left side in 16 patients (43.2%) and the right side in 21 patients (56.8%). The most common cause of this type of injury was traffic accidents (7 patients, 18.9%), followed by football (6 patients, 16.2%), basketball (6 patients, 16.2%), skiing (4 patients, 10.8%) and other sports. Among local patients, there was a mean BMI of 26.8 ± 4.6 (range 21.6–35.4) and a mean pre-injury Tegner score of 7.6 ± 1.1 (range 6–9), and none of these patients had any limitation of knee movement in their daily lives prior to the injury.

Table 1

Patient characteristics and preoperative parameters^a
Characteristics	Total cases (n = 37)	Single surgery (n = 15)	Staged surgery (n = 22)	P Value
Age, y	29.3 ± 9.7 (15–50)	33.0 ± 9.8 (17–50)	26.7 ± 9.0 (15–47)	0.053
Sex				0.505
Female	2 (5.4%)	0 (0.0%)	2 (9.1%)
Male	35 (94.6%)	15 (100.0%)	20 (90.9%)
Follow-up, y	2.5 ± 2.2 (0.5–11.4)	2.1 ± 1.4 (1–6)	2.7 ± 2.7 (0.5–11.4)
Side				0.336
Left	16 (43.2%)	8 (53.3%)	8 (36.4%)
Right	21 (56.8%)	7 (46.7%)	14 (63.6%)
Combined injuries
MCL	26 (70.3%)	8 (53.3%)	18 (81.8%)	0.080
LM	15 (40.5%)	9 (60.0%)	6 (27.3%)	0.087
MM	16 (43.2%)	8 (47.1%)	8 (36.4%)	0.336
None	3 (8.1%)	1 (6.7%)	2 (9.1%)	1.000

^a Data are reported as n (%) or mean ± SD (range). If there are data missing, the proportions of effective cases are presented; SD, standard deviation; MCL, medial collateral ligament; MM, medial meniscus; LM, lateral meniscus.

34 patients (91.2%) had a combination of other knee structure injuries (Table 1), most commonly MCL (26 patients, 70.3%), followed by medial meniscus (MM, 16 patients, 43.2%) and lateral meniscus (LM, 15 patients, 40.5%). All patients underwent PT repair during the initial surgery. 15 patients (40.5%) underwent single surgery and 22 patients (59.5%) underwent staged surgery, with a mean interval between two operations of 4.7 ± 2.5 (range 1.3–10) months. The baseline characteristics of the patients who underwent different surgical strategies had no significant difference (Table 1).

According to the follow-up assessments (Table 2), 23 patients (88.5%) returned to sports after surgery and 13 patients (59.1%) were able to return to their pre-injury level of sports. The mean Lysholm score was 89.1 ± 12.3 (range 49–100), and the mean IKDC score was 85.4 ± 13.0 (range 56–100). Postoperative complications included infection, stiffness, arthrofibrosis and mechanical arthritis. In local patients, the mean postoperative Tegner score was 5.9 ± 2.3 (range 4.0–9.0), which is significantly lower than the pre-injury Tegner score (P = 0.016). 8 patients (80.0%) returned to sports at a mean time of 7.6 ± 3.4 (range 3–12) months.

Table 2

Follow-up assessments^a
Characteristics	Total cases (n = 37)	Single surgery (n = 15)	Staged surgery (n = 22)	P Value
Return to sports	23 (88.5%; 26/37)	11 (100.0%; 11/15)	12 (80.0%; 15/22)	0.238
Return to pre-injury level of sports	13 (59.1%; 22/37)	5 (33.3%; 9/15)	8 (61.5%; 13/22)	1.000
Lysholm score	89.1 ± 12.3 (49–100; 24/39)	84.8 ± 15.7 (49–100; 11/15)	92.7 ± 7.2 (75–100; 13/22)	0.186
IKDC score	85.7 ± 12.5 (56–100; 23/39)	80.2 ± 17.4 (56–100; 11/15)	89.2 ± 7.1 (80.5–100; 12/22)	0.173
Complications	5 (13.5%; 5/37)	5 (33.3%; 5/15)	0	0.007

^a.Data are reported as n (%) or mean ± SD (range). If there are data missing, the proportions of effective cases are presented; SD, standard deviation; IKDC, International Knee Documentation Committee.

In terms of knee function assessments (Table 2), the Lysholm (84.8 ± 15.7vs. 92.7 ± 7.2) and IKDC (80.2 ± 17.4vs. 89.2 ± 7.1) scores did not show a significant difference among patients who underwent different surgical strategies (P = 0.186 and P = 0.173, respectively). Postoperative complications occurred in 5 (33.3%) and 0 patients after the single and staged surgery, respectively, with the former being significantly more frequent than the latter (P = 0.007). The proportion of return to (pre-injury level) sports did not differ significantly between patients receiving different surgical strategies. Linear regression of postoperative knee function scores showed that surgical strategy did not significantly affect postoperative Lysholm and IKDC scores (P = 0.294 and P = 0.270, respectively) (Table 3).

Table 3

Liner regression for Lysholm and IKDC score^a
Characteristics	Beta	SE	95% CI	P value
Lysholm score
Age	0.180	0.325	-0.506-0.866	0.586
Follow-up	0.832	1.628	-2.604-4.267	0.616
MCL	6.367	7.871	-10.240-22.973	0.430
LM	7.233	6.440	-6.354-20.820	0.277
MM	-2.823	5.877	-15.223-9.577	0.637
Surgical strategy	7.905	7.293	-7.481-23.292	0.294
IKDC score
Age	-0.044	0.399	-0.900-0.812	0.914
Follow-up	0.988	1.733	-2.728-4.704	0.577
MCL	-0.663	8.983	-19.930-18.604	0.942
LM	5.548	7.991	-11.592-22.688	0.499
MM	3.491	6.618	-10.704-17.685	0.606
Surgical strategy	9.448	8.230	-8.203-27.099	0.270

^aSE, standard error; CI, confidence interval; MCL, medial collateral ligament; MM, medial meniscus; LM, lateral meniscus; IKDC, International Knee Documentation Committee.

In this retrospective case series and systematic review, patients with simultaneous ruptures of PT and ACL who underwent different surgical strategies did not show significant differences in knee function scores and return to (pre-injury level) sports at an average of 2.5 years postoperatively, but had a higher incidence of complications after single surgery than staged surgery. We recommend that patients with this type of injury undergo staged surgery to minimize complications if a quick return to sports is not desired.

There is a consensus that early PT repair is necessary after injury, and there is still a controversy regarding the timing of ACL reconstruction[1, 3, 21]. For single surgery, simultaneously performing PT repair and ACL reconstruction reduces the trauma to patients due to the fewer surgeries, and combines the rehabilitation of both structures, allowing patients to return to sports in a short period of time[15]. Shortening possible recovery time is important in elite sports[13]. However, facilitating early postoperative knee motion is essential to promote ACL recovery, but a gentle rehabilitation program that gradually increases ROM and training intensity is usually followed after PT repair, thus, two conflicting rehabilitation programs may increase the risk of postoperative complications[1, 3, 6, 11].

We noticed that some patients who underwent single surgery had no complications during follow-up and had good knee function scores, which may be attributed to changes in surgical techniques and rehabilitation protocols. Selva-Sarzo et al used additional tissue from the hamstring tendon as a support for repaired PT [13]. In the studies by Kim et al and Scrivano et al, patients started earlier knee exercises at 2 weeks after surgery[11, 14]. Kim et al mentioned bases for selecting a single surgery, such as the relative youth of the patients and the acute phase of the injury[11]. These applicable conditions and improved techniques reduced the impact of the conflicting rehabilitation programs to some degree.

However, except for athletes with a high expectation for rapid recovery, early ACL reconstruction is not recommended in the general population[22, 23]. Numerous studies have demonstrated that patients who underwent preoperative rehabilitation, including neuromuscular and strength training during the period between injury and surgery, had better postoperative outcomes than those who simply received early ACL reconstruction[1, 24–28]. Meanwhile, A five-year prospective study also discovered that early (≤ 6 months) or delayed (> 6 months) ACL reconstruction had no significant impact on postoperative functional outcomes in patients who underwent preoperative rehabilitation, justifying the rationale for delayed reconstruction[22]. The strategy of staged surgery also has limitations, Granan et al found that the risk of cartilage injuries and meniscal tears increased with the delay from injury to ACL reconstruction[29]. Although none of patients with simultaneous ruptures of PT and ACL did not mention postoperative cartilage injuries and meniscal tears, it may be meaningful to evaluate these indicators by magnetic resonance imaging in the follow-up of patients undergoing staged surgery.

In the 17 studies reviewed, 1 study recommended single surgery[15], 6 studies recommended staged surgery[6, 16, 21, 30–32], 2 studies did not mention a specific viewpoint[11, 33], and the remaining 8 studies suggested a combination of considerations[2–4, 10, 12–14, 34], such as single surgery is more recommended for professional athletes, staged surgery is more recommended for combined MCL rupture, or taking surgeon’s and patient’s preferences into account. In most patients, time to return to sports is generally the second most important factor to consider, after avoiding complications, except for those patients where professional athletes require a quick return to sports. In this case series and literature review, we found that postoperative complications were more frequent after single surgery than after staged surgery, which means staged surgery may be a better strategy for those without an urgent need to return to sports.

Despite the dramatic nature of the injury, most patients observed were able to regain good knee function and return to sports. However, only 59.1% patients were able to return to their pre-injury sports level, and that without considering selection bias. Both physical functioning and psychological factors are important components for patients to return to sports[35, 36]. We observed differences in the frequency of complications between the surgical strategies, but there was no difference in the proportion of return to (pre-injury level) sports. Psychological factors have received much attention in recent years in the study of return to sports after injury, and psychological readiness was found to be the most significant factor related to return to pre-injury level of sports after ACL reconstruction[37–39]. There was also a patient who did not return to exercise due to fear of re-injury in previous study[31]. In local cases, psychological factors that contributed to patients' failure to return to pre-injury level of sports included fear of sports, fear of re-injury, fear of the long rehabilitation period, and family and work demands that took precedence over pre-injury level sports. Supplementary interventions to address specific psychological factors may play a beneficial role in the return to sports of such patients, an issue that deserves further investigation.

The contribution of this study is that the prognosis between two surgical strategies was compared firstly for this type of combined injuries, and more single-center patients were reported, which to our knowledge is the largest case series of simultaneous PT and ACL ruptures ever reported, as well as in the review of previously reported patients, which will provide surgeons with a detailed reference to characterize the disease and guide management.

The limitation is that the total case volume was still small because of the rarity of this disease. Meanwhile, as postoperative complications were not observed in patients with staged surgery, binary logistic regressions on possible factors influencing complications can't be performed. The lack of postoperative assessment in some patients may introduce selection bias, which may have obscured or exaggerated the effect of surgical strategy. Heterogeneity in surgical techniques, patient assessments and postoperative protocols could not be avoided as many patients came from other studies. In the future, more multicenter cohort studies are needed to provide more evidence.

Patients with simultaneous ruptures of PT and ACL who underwent different surgical strategies did not show significant differences in knee function scores and return to (pre-injury level) sports at an average of 2.5 years postoperatively, but had a higher incidence of complications after single surgery than staged surgery. We recommend that patients with this type of injury undergo staged surgery to minimize complications if a quick return to sports is not desired.

ACL, anterior cruciate ligament;

BMI, body mass index;

IKDC, International Knee Documentation Committee;

LM, lateral meniscus;

MCL, medial collateral ligament;

MM, medial meniscus;

PT, patellar tendon;

ROM, range of motion.

Ethics approval and consent to participate: This work was approved by the ethics committee of Peking University Third Hospital (Project Number: M2023562). Every human participant gave informed consent to participate in the study.

Consent for publication: All authors whose names appear on the submission 1) final approval of the version to be published. 2) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Availability of data and materials: The authors confirm that the data supporting the findings of this study are available within the article.

Competing interests: The authors declare they have no competing interests.

Funding: This work was supported by grants from Key Clinical Projects of Peking University Third Hospital (Grant No. BYSYZD2021021) from Peking University Third Hospital.

Authors' contributions: All authors contributed to the study conception and design. Detailed contributions are as follows: H.-R. S. (conceptualization, data collection and draft writing), X. G. (data collection, statistical analysis and draft writing), C. W. (data collection and statistical analysis), H.-J. W. (surgical data provision and draft revision), Y.-T. G. (surgical data provision and draft revision), J. W. (statistics analysis and draft revision), Y. M. (surgical data provision and draft revision), J.-Q. W. (supervision and draft revision), W.-L. S. (conceptualization, surgical data provision and draft revision). All authors read and approved the final manuscript.

Acknowledgements: Not applicable.

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Higher Incidence of Postoperative Complications in Patients with Simultaneous Patellar Tendon and Anterior Cruciate Ligament Ruptures Following Single Surgery: A Case Series and Literature Review

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Background

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