Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Meta-analytical grafting: a patient's and clinician's perspective
- Sanjay Purkayastha (17 April 2006)
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Re: Meta-analytical grafting: a patient's and clinician's perspective
- David J Biau (20 April 2006)
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When to operate
- peter mrak (25 April 2006)
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conservative treatment and ACL tear: a need for more scientific evidence?
- David J Biau (26 April 2006)
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Need for an International Database & Use of Validated Scoring Systems
- Turab A SYED (2 May 2006)
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Patellar tendon vs Hamstring grafts for ACL reconstruction -which is better?
- S THOMAS (4 May 2006)
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Author's reply
- David J Biau (5 May 2006)
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Sanjay Purkayastha, Clinical Research Fellow Department of Biosurgery & Surgical Technology, Imperial College, London W2 1NY
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Dear Sir, I read the meta-analysis comparing bone-patella-bone and hamstring tendon autografts for anterior cruciate ligament (ACL) reconstruction by Biau and colleagues [1] with great interest from two perspectives. Firstly as a patient who has had a bone patella bone graft for ACL reconstruction 5 years ago and secondly as a clinician with an interest in meta-analysis and its methodology. As a patient, from my own anecdotal experience of morbidity following the procedure I agree with the authors’ findings especially with regards to anterior knee pain, which can still be very troublesome at times. Interestingly, the authors’ conclusions also stress the importance of discussing such potential problems preoperatively with patients, especially those from Asia. Being Indian in origin, I would further support this statement - there have been many occasions where sitting cross-legged or kneeling for periods of time has been necessary at religious or social events which has led to serious discomfort afterwards. From a clinician and researcher’s point of view, I congratulate the authors on their sound methodology used in this meta-analysis and on their findings, especially as there is very little heterogeneity between the studies. However, although the quality of the studies was assessed and was found to be poor in general, there is no discussion of publication bias which may be an important limitation to the interpretation of the results. Also, I note that the mean follow up of the included studies ranges from 12 to 102 days, the majority being well under 50 days. This also may potentially limit the inferences that can be made from the findings of this meta-analysis, as certainly from my own personal experience there was still considerable rehabilitation, tissue healing and muscle strengthening needed 4 months after the initial procedure and I am sure that this is the case for many patients. There was no mention of cost in the article (both financial and quality of life). I am sure that at present such comparative data is hard to come by, but the time and effort (of the patient, practitioners and physiotherapists etc) necessary to achieve a complete return to normal activities is significant and since the majority of patients who undergo these procedures are young and active, these are considerations which I would certainly look into now if I were to undergo ACL reconstruction now. Yours sincerely Mr. Sanjay Purkayastha BSc MBBS MRCS Clinical Research Fellow References: [1] Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS. Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ. 2006 Apr 7; doi: 10.1136/bmj.38784.384109.2F (last accessed 16th April 2006) Competing interests: None declared |
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David J Biau, specialist orthopaedic registrar Paris - France
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Dear Sir, We would like to thank Dr Purkayastha for his comment on our work. We feel both perspectives are very interesting. On the patient’s side, we hope that doctors will give more information about the outcome and the problems related to both reconstructions and that hamstring autografts will be shown more interest from young orthopaedic surgeons. On the researcher’s side, it is true that meta-analyses are not free of bias and that one should not consider it as a definite answer. It may help in summarising the evidence in a clearer way, as was the case for the morbidity yielded by the two types of reconstruction. It may help in defining the question more precisely, as was the case for stability outcomes. And it may certainly help in pointing out the limitation of the evidence available and the quality of the evidence produced in the surgical literature. There is a need for improving the quality of reporting in surgical trials and there is a need for doing multicentre RCTs to overcome sample size issues. We are currently performing a meta- analysis based on individual patient data with the help of the principal investigators of the trials; this should be step forward, but certainly not the last step to take. The issue of cost, both financial and quality of life, was not taken into account as it was never reported in the trials selected; it would surely be interesting to assess theses issues and may help further in deciding which graft to choose. As for the mean follow-up time, it was not from 12 days to 102 days but from 12 months to 102 months. The authors are sorry for having overlooked this error in the proofs and that it has misled the reader, although not quite so: studies that had not a minimum of 12 months follow-up were excluded from the analysis, because, as noted Dr Purkayastha, patient do need a certain time to recover from this operation. Dr David Biau, for the study goup. Competing interests: None declared |
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peter mrak, internist A-8112 Gratwein, Austria
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Thank you very much for your fine Meta-analysis. I would find it also very important to help patients and their doctors in their decisionmaking on when to operate at all and when to decide for a conservative approach. As you point out correctly in your Introduction, the decision about the technique of surgery is made by the referring practitioner by choosing the surgeon , but also the decision to operate at all is made additionally by the surgeon , unfortunately often based on fee for service objectives, however the outcomes remain controversial, as is clearly pointed out in your recent Metaanalysis. I think it would therefore be of great interest to patients and their doctors , to add an additional controll group of conservatively treated patients, means without surgery at all , into the evaluation of long term outcomes of anterior cruciate ligament rupture and its appropriate treatment. thank you, sincerly Dr. Peter Mrak Competing interests: None declared |
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David J Biau, specialist orthopaedic registrar Paris - France
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Dear Sir, We would like to thank Dr Mrak for his appropriate comment relating to our work. The indication for operation was not the subject of the analysis but, as points out Dr Mrak, remains vague for some patients and therefore to some doctors. The prime indication for anterior cruciate ligament reconstruction is symptomatic instability; the aim of anterior cruciate ligament reconstruction is to restore functional stability without compromising other joint function (ie, full range of movement and no pain). [1] Therefore what holds for a twenty-year old young patient practising contact sports may not for a thirty-year old patient who is sedentary and has no complaints regarding his knee (no episode of instability) and this whether or not the knee is unstable on clinical examination. Therefore, the indication may sometimes be equivocal and is best chosen after discussion with the patient. Meniscal injury at MRI scan may weight for the operation. The reason why indication for reconstruction is not clear cut is that we lack scientific evidence that it prevents from late osteoarthritis, and this is the second point we would like to discuss. The scientific basis for anterior ligament reconstruction is that early stabilization reduces the incidence of meniscal pathology, which may in turn have a protective effect on cartilage damage. However, so far and to the best of our knowledge, there is evidence that operative treatment yields better functional results, but there is no evidence that anterior cruciate ligament reconstruction prevents from late osteoarthritis and this despite few randomized controlled clinical trials and meta-analysis. [2-4] Now the reason why we lack sound scientific ground to rely on when offering someone a reconstruction is due to the difficulty to conduct surgical randomized controlled clinical trials and this is our third point. [5] We appreciate Dr Mrak’s comment that conservative groups should be included with treatment groups. However, in surgery, as opposed to pharmacological trials, there is sometimes such an easy and visible evidence that link the pathology, the treatment and the results that it proves very difficult ‘no to treat’ the patients. Chalmers said: “randomize the first patient” but due to learning curve, reluctance of surgeons for evaluation and the ‘impossible’ state of equipoise necessary to randomized trials, we don’t and then it’s too late! Nowadays it would seem almost unethical not to reconstruct a patient who has a symptomatic unstable knee due to ACL tear. [1] ACL reconstruction: best practice. Available at: http://www.boa.ac.uk/PDF%20files/BASK/ACL%20best%20practice.pdf [2] Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am. 1987 Oct;69(8):1120-6. [3] Andersson C, Odensten M, Good L, Gillquist J. Surgical or non- surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up. J Bone Joint Surg Am. 1989 Aug;71(7):965-74. [4] Hinterwimmer S, Engelschalk M, Sauerland S, Eitel F, Mutschler W. [Operative or conservative treatment of anterior cruciate ligament rupture: a systematic review of the literature] Unfallchirurg. 2003 May;106(5):374-9. German. [5] McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised trials in surgery: problems and possible solutions.BMJ. 2002 Jun 15;324(7351):1448-51 Competing interests: None declared |
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Turab A SYED, Specialist Registrar Trust Trauma & Orthopaedics Milton Keynes General Hspital NHS Trust, Milton Keynes, Mk6 5LD, United Kingdom
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I read with interest the meta-analysis published by David Baiu (1) and corresponding four Rapid Responses explaining patient's choice and perspective. Jury still seems to be out on which one is a better fixation. Proponents for PTB Graft would profess that the graft would integrate into Bony Tunnel better than Hamstrings graft. I accept that the incidence of Anterior Knee Pain would be greater with PTB than Hamstrings Graft. In some societies this may not be acceptable at all, as in Muslim World & Middle East where patients would have to kneel several times per prayer and up to five different times of the day for their prayers. This would surely mean a poor quality of life! It would also be important to know what would patient prefer, as a professional may have different expectations from someone who is a keen sportsperson ( either male or female). These both surgeries have been around for sometime and yet we have to wait for a multicentre trial to decide the issue. With the current advancement of technology and the number of operation performed per year alone in United States (2) it is a shame that we don’t have a system whereby all this valuable information being generated can be interpreted. In the U.S. in 1996, doctors performed ACL repairs on more than 100,000 patients across ambulatory (72,000) and inpatient (35,300) settings. In the U.S. in 2003, doctors performed 8,900 ACL tears in inpatient care I would suggest that all surgeons either doing PTB or Hamstrings should be asked to use a SINGLE VALIDATED FUNCTIONAL SCORING SYTEM / QUESTIONNAIRE both pre-operative & Post Operatively for every single surgery as expectations may be different on the basis of gender. In 2003, the inpatient data shows that 44% of ACL tear repairs were performed on women and 56% on men.(2) This information perhaps can be collected online as is currently being done so for NJR ( National Joint Registry on the same basis as Swedish Hip Register). It is well established that national register for surgical procedures have benefits. So why not extend them internationally when this is not so difficult with availability of internet. This would allow us to have something similar to multicentre trial. As the final outcome would be dependant on the skill of the operating surgeon and which technique they have been using. This could be a good trade-off to randomization. The numbers available from North America suggest if similar number of operations are being carried out in Europe & United Kingdom, it would be matter of couple of years before we have evidence in front of us! Perhaps this is the time when international orthopaedic organizations like SICOT (Société Internationale de Chirurgie Orthopédique et de Traumatologie) or EFORT (European Federation of National Associations of Orthopaedics and Traumatology) should rise to the occassion. (1)David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J Schranz, and Rémy S Nizard Bone-patellar tendon-bone auto grafts versus hamstring auto grafts for reconstruction of anterior cruciate ligament: meta-analysis BMJ 2006; 332: 995-1001 (2)http://www.aaos.org/wordhtml/research/stats/ACLRepairfacts.htm accessed on 01 May 2006 Competing interests: Specialist Registrar Trauma & Orthopaedics performing PTB ACL Reconstructions |
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S THOMAS, Clinical fellow North Tyneside Hospital, Tyne and Wear,UK.
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Dear editor, This article has been read with great interest. The methodology used is being greatly appreciated, however I would like to highlight few points. 1. While comparing the two methods used for auto grafts, more emphasis is being made on the morbidities caused by patella tendon grafts (anterior knee pain, loss of extension, impingement and arthrofibrosis) while the morbidities which can be caused by hamstring grafts have been left without much mention. 2. The economic aspects of these methods and the difference in operating times have not been referred to. Forssblad et al [1] has shown that there is a considerable cost difference between these two. 3. The symptoms of knee pain while squatting and kneeling following hamstring grafts have been well documented. Goradia et al [2] showed an incidence of 38% knee pain due to different reasons in their series following hamstring grafts. References 1. David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J Schranz, and Rémy S Nizard. Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ 2006; 332: 995-1001. 2. Forssblad M, Valentin A, Engstrom B, Werner S. ACL reconstruction: patellar tendon versus hamstring grafts-economical aspects. Knee Surg Sports Traumatol Arthrosc. 2006 Mar 29. 3. Goradia VK, Grana WA, Pearson SE. Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts. Arthroscopy. 2006 Jan;22(1):80 Competing interests: None declared |
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David J Biau, specialist registrar orthopaedics and trauma Paris - France
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Dear sir, we would like to thank both Dr Syed and Dr Tomas for their relevant comments. It is true that randomised controlled clinical trials may not be well adapted for surgical evaluation. A multicentre database where all reconstructions would be recorded may be more adequate. The great amount of information that would be generated owing to the number of reconstructions performed each year would probably answer many questions. However, as noted Dr Syed, there are many difficulties to overcome. The standardisation of reporting, the willingness to share results, the extra time and money that would need to be funded... The economic importance of anterior cruciate ligament reconstruction is not that of joint replacement and therefore, the solution is unlikely to come from public health authorities. However, a multicentre online database, starting with only a few dedicated centres with high volume of reconstruction, led by an expert society may be an answer. As for the three points developped by Dr Tomas: 1. The specific morbidity caused by hamstring autografts tendon is not reported thouroughly in enough studies to allow for a fair comparison. The muscle torque (hamstring and quadriceps) was unfortunately reported with too many differences between studies to be agregated. Hamstring tenderness is not well documented, and we believe it may be less important than anterior knee pain. 2. The economic aspects of these methods have not been referred to because we had to limit results and discussion to the materials and it was not assessed by trialists. However, the increased cost of 300 to 400 euros reported by Forssblad et al.[1] for hamstring reconstructions should be balanced by the increased morbidity generated by patellar tendon reconstruction during the first year and after. It may prove that patellar reconstructions are less cost-effective in the long term. 3. Hamstring autgraft reconstructed patients may report anterior knee symptoms (69 of 536 patients, 13%), but still, less than patellar tendon reconstructed patients (105 of 475 patients, 22%).[2] However, we agree that it is far from being morbidity free. References 1. Forssblad M, Valentin A, Engstrom B, Werner S. ACL reconstruction: patellar tendon versus hamstring grafts-economical aspects. Knee Surg Sports Traumatol Arthrosc. 2006 Mar 29. 2. David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J Schranz, and Rémy S Nizard. Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ 2006; 332: 995-1001. Competing interests: None declared |
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