Anterior cruciate ligament reconstruction with the bone-patellar tendon-bone graft with and without a ligament augmentation device: A 25-year follow-up of a prospective randomized controlled trial.
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Background: Various grafts and ligament augmentation devices (LADs) have been used during the last decades in the search for the optimal reconstruction of the anterior cruciate ligament (ACL) providing safe and effective healing. Purpose: To compare the 25-year follow-up results after ACL reconstruction with bonepatellar tendon-bone (BPTB) graft with or without the Kennedy LAD. Study Design: Randomized controlled clinical trial. Methods: A total of 100 patients undergoing ACL reconstruction between 1991 and 1993 were randomized into two groups; reconstruction with BPTB graft (BPTB group) or BPTB graft with the Kennedy LAD (LAD group). There were 51 patients in the BPTB group and 49 patients in the LAD group. The current 25-year follow-up evaluation included clinical knee examination, various patient reported outcomes and assessment of radiographical osteoarthritis (OA) according to the Ahlbäck classification. Additional outcomes were number of patients with reruptures and knee arthroplasties. Results: A total of 93 patients (93%) were available for follow-up evaluation; 48 patients in the BPTB group and 45 patients in the LAD group. Most of the patients had a negative or 1+ Lachman and Pivot shift result. Mean Lysholm functional score was 85 for the BPTB group and 83 for the LAD group. All of the mean Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores were above 70, with the best results for Pain, Symptoms and Activities of Daily Living (ADL). There were no statistically significant differences between the groups regarding any of these outcomes, the Tegner activity scale, radiological assessments of OA or number of ACL reruptures. There was, however, a significant difference in the mean side-toside difference with the KT-1000 arthrometer between the two groups in favor of the LAD group (P = 0.021). Signs of radiographical OA was detected in all patients and severe radiographical OA, defined as Ahlbäck III, IV or V, was detected in 32% of the patients in the BPTB group and 21% of the patients in the LAD group (P = 0.37). One patient in the BPTB group and six in the LAD group had undergone knee arthroplasty (P = 0.054). Conclusion: In the present study, patients with BPTB graft with or without LAD show good clinical and subjective outcomes 25 years after ACL reconstruction. All patients in both groups had signs of radiographical OA, however less than one-third of the patients in both groups had severe radiographical OA. There was a tendency towards more knee arthroplasties in the LAD group compared with the BPTB group.