Comparison of hamstring and patellar tendon grafts in anterior cruciate ligament reconstruction: A prospective randomized study

Hamstring Tendon Autograft Is Associated With Increased Knee Valgus Moment After Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis

BACKGROUND

There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR).

PURPOSE/HYPOTHESIS

This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone-patellar tendon-bone autograft at 6 months postoperatively in an adolescent population. The authors' hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used.

STUDY DESIGN

Controlled laboratory study.

METHODS

Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb.

RESULTS

A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg (P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10-2 vs -35 × 10-2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10-2 vs -4 × 10-2 N·m/kg, respectively; P = .0426). Both the QT with bone block (-12 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0265) and QT (-13 × 10-2 vs -3 × 10-2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group.

CONCLUSION

The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft.

CLINICAL RELEVANCE

This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis

Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.

Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups.

RESULTS

Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.).

CONCLUSION

ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events.

LEVEL OF EVIDENCE

Level I.

Canine ACL reconstruction with an injectable hydroxyapatite/collagen paste for accelerated healing of tendon-bone interface

Healing of an anterior cruciate ligament (ACL) autologous graft in a bone tunnel occurs through the formation of fibrovascular scar tissue, which is structurally and compositionally inferior to normal fibrocartilaginous insertion and thus may increase the reconstruction failure and the rate of failure recurrence. In this study, an injectable hydroxyapatite/type I collagen (HAp/Col Ⅰ) paste was developed to construct a suitable local microenvironment to accelerate the healing of bone-tendon interface. Physicochemical characterization demonstrated that the HAp/Col Ⅰ paste was injectable, uniform and stable. The in vitro cell culture illustrated that the paste could promote MC3T3-E1 cells proliferation and osteogenic expression. The results of a canine ACL reconstruction study showed that the reconstructive ACL had similar texture and color as the native ACL. The average width of the tunnel, total bone volume, bone volume/tissue volume and trabecular number acquired from micro-CT analysis suggested that the healing of tendon-bone interface in experimental group was better than that in control group. The biomechanical test showed the maximal loads in experimental group achieved approximately half of native ACL's maximal load at 24 weeks. According to histological examination, Sharpey fibers could be observed as early as 12 weeks postoperatively while a typical four-layer transitional structure of insertion site was regenerated at 48 weeks in the experimental group. The injectable HAp/Col Ⅰ paste provided a biomimetic scaffold and microenvironment for early cell attachment and proliferation, further osteogenic expression and extracellular matrix deposition, and in vivo structural and functional regeneration of the tendon-bone interface.

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A stable and injectable HAp/Col I paste was designed, optimized and characterized.

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The paste was applied in ACL reconstruction with an established standard operation procedure.

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Provided the safety and efficacy evidence for ACL reconstruction, and healing of tendon-bone interface was accelerated.

Hamstring Graft Preparation for ACL Reconstruction

Anterior cruciate ligament (ACL) reconstruction represents one of the most common procedures in orthopedic surgery. It usually involves the harvest of both gracilis and semitendinosus tendons from the ipsilateral knee. Different methods of hamstring graft preparation have been proposed in recent years, to create an adequate graft diameter reducing morbidity linked to gracilis tendon harvesting procedure. More recently, the use of only 1 of the tendons (semitendinosus) in a tripled or quadrupled arrangement has been described, especially in an all-inside type of reconstruction. Having a thicker tendon with a quadrupled semitendinosus (ST), instead of double gracilis and ST enables to have a graft with enough diameter to resemble more closely the native ACL and decreases the risk of graft re-rupture. The present study aims to describe different options of hamstring graft preparing, listing and analyzing each configuration to help surgeons to choose the most suitable graft type for their patients.

Return to Baseline Physical Activity After Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts are the most utilized grafts for primary anterior cruciate ligament (ACL) reconstruction. The ability of a patient to return to a preinjury level of physical activity is a key consideration in choice of graft; the influence of graft choice on this metric lacks consensus in the literature.

PURPOSE

To assess the effects of autograft choice (BPTB vs HT) for primary ACL reconstruction on return to baseline level of physical activity and/or sports participation.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

A systematic review of randomized controlled trials comparing the use of BPTB and HT autografts for primary ACL reconstruction was conducted. The electronic databases EMBASE, MEDLINE, Cochrane CENTRAL, and Web of Science were comprehensively queried through September 23, 2019. The primary outcome was return to preinjury level of activity/sports. Secondary outcomes included knee stability testing (Lachman, KT-1000 arthrometer, and pivot-shift tests) and clinical subjective knee scores (Tegner, Cincinnati, International Knee Documentation Committee, and Lysholm). Two independent reviewers were involved in the screening of titles and abstracts, data extraction, and the assessment of risk of bias. Meta-analyses were performed respecting the Cochrane Handbook for Systematic Reviews of Intervention.

RESULTS

A total of 29 studies (N = 3099 patients) were eligible for this review, of which 13 (n = 1029 patients) reported on return to baseline level of sports as an endpoint. The risk ratio (RR) of using BPTB vs HT on return to baseline sport level was 1.03 (0.91-1.17; P = .63). Absence of a positive pivot-shift test was the only secondary outcome, with a statistically significant RR of 0.66 (95% CI, 0.50-0.86) in favor of BPTB autografts (P = .002).

CONCLUSION

In reviewing the current literature, no recommendation can be made on the optimal graft choice when using a return to baseline level of physical activity and/or sports participation as a primary metric.

Relation of peroneus longus autograft dimensions with anthropometric parameters in anterior cruciate ligament reconstruction: Importance of the distal leg diameter

Objectives

This study aims to investigate the relationship between various anthropometric parameters and the diameter and length of the peroneus longus tendon (PLT) graft in the anterior cruciate ligament (ACL) reconstruction.

Patients and methods

A total of 52 patients (38 males, 14 females; mean age: 29.2±7.7 years; range, 17 to 51 years) who received PLT autograft for ACL reconstruction in our center between July 2018 and June 2020 were retrospectively analyzed. Demographic characteristics of the patients and leg length, and proximal and distal leg diameters were recorded before the operation. The PLT autograft diameter and length were measured during surgery.

Results

A statistically significant correlation was found between the graft diameter and length and weight, height, body mass index (BMI), leg length, and proximal and distal leg diameters (p<0.01). There was no statistically significant correlation between the graft diameter and length and age (p>0.05). Distal leg diameter had the highest correlation coefficient for the PLT autograft diameter (r=0.956), while the height had the highest correlation coefficient for the PLT autograft length (r=0.982).

Conclusion

Anthropometric parameters of height, weight, BMI, leg length, and proximal and distal leg diameters may be helpful for surgeons to predict the diameter and length of the PLT autograft before surgery. Distal leg diameter is a particularly important parameter in predicting PLT autograft diameter.

Return to Sport After ACL Reconstruction With a BTB Versus Hamstring Tendon Autograft: A Systematic Review and Meta-analysis

Background

Anterior cruciate ligament (ACL) tears are debilitating injuries frequently suffered by athletes. ACL reconstruction is indicated to restore knee stability and allow patients to return to prior levels of athletic performance. While existing literature suggests that patient-reported outcomes are similar between bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts, there is less information comparing return-to-sport (RTS) rates between the 2 graft types.

Purpose

To compare RTS rates among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft.

Study Design

Systematic review; Level of evidence, 4.

Methods

The MEDLINE, Embase, and Cochrane Library databases were searched, and studies that reported on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Studies that utilized ACL repair techniques, quadriceps tendon autografts, graft augmentation, double-bundle autografts, allografts, or revision ACL reconstruction were excluded. RTS information was extracted and analyzed from all included studies.

Results

Included in the review were 20 articles investigating a total of 2348 athletes. The overall RTS rate in our cohort was 73.2%, with 48.9% returning to preinjury levels of performance and a rerupture rate of 2.4%. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 81.0%, with 50.0% of athletes returning to preinjury levels of performance and a rerupture rate of 2.2%. Patients after primary ACL reconstruction with an HT autograft had an overall RTS rate of 70.6%, with 48.5% of athletes returning to preinjury levels of performance and a rerupture rate of 2.5%.

Conclusion

ACL reconstruction using BTB autografts demonstrated higher overall RTS rates when compared with HT autografts. However, BTB and HT autografts had similar rates of return to preinjury levels of performance and rerupture rates. Less than half of the athletes were able to return to preinjury sport levels after ACL reconstruction with either an HT or BTB autograft.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion": A Randomized Clinical Trial

BACKGROUND

The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction.

PURPOSE

This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft.

MATERIALS AND METHODS

One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score.

RESULTS

Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain.

CONCLUSION

There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Predicting the peroneus longus tendon autograft size in ACL reconstruction by using anthropometric parameters: A study in South Sulawesi population

Introduction

Some literature use peroneus longus tendon (PLT) as the alternative to anterior cruciate ligament (ACL) reconstruction to overcome inadequate autograft size potential risk by using hamstring tendon (HT) autograft. Among the available methods to predict PLT measurements, anthropometric parameters are one of the most accessible and feasible methods. The objective of this prospective study was to predict the PLT autograft sizes in single bundle ACL reconstruction by using preoperative anthropometric measurement.

Method

Anthropometric parameters, including age, gender, height, weight, body mass index (BMI), true leg length (TLL), shank circumference and shank length of 20 patients with primary ACL reconstruction was measured before surgery. Univariate analysis, independent-sample t-test, Pearson correlation test, and logistic regression to evaluate the influence of these anthropometric variables on the diameter and length of the PLT autograft obtained.

Result

Pearson correlation test has shown that body weight and height correlates to PLT length and diameter also autograft's length and diameter significantly (p < 0.05). The linear regression analysis showed that height, weight, TLL and shank length were signifcantly related to autograft diameter. While height and TLL were significantly related to autograft length.

Conclusion

Height, weight, TLL and shank length can use to predict PLT autograft diameter. While height and TLL can use to predict PLT autograft length.

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It is important to estimate tendon graft size prior to ACL reconstruction surgery.

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Preoperative anthropometric measurement is a good method to predict PLT autograft size.

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Height is a good predictor of the PLT autograft diameter and length.

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Patient less than 153 cm in height, high risk for having in adequate graft size.

Single-tunnel anatomic double-bundle anterior cruciate ligament reconstruction has the same effectiveness as double femoral, double tibial tunnel: A prospective randomized study

PURPOSE

To investigate whether single femoral, single tibial tunnel anatomic double-bundle anterior cruciate ligament (ACL) reconstruction is equal to or superior to double femoral, double tibial tunnel ACL double-bundle anatomic reconstruction in terms of restoring the stability and functions of the knee joint.

METHODS

A prospective clinical study was performed to compare 30 cases of single-tunnel ACL double-bundle anatomic reconstruction to 28 cases of double-tunnel ACL double-bundle anatomic reconstruction, with average follow-up of 36 months. All graft tendons were hamstring tendon autografts. Tunnel placements in all the cases were made anatomically. Clinical results were collected after reconstruction. Graft appearance, meniscus status and cartilage state under arthroscopy were compared and analyzed.

RESULTS

Tunnel placements were in the anatomic positions in both groups. On the lateral pivot-shift test performed at 36 months postoperatively, there was no significant difference between groups. Clinical results such as International Knee Documentation Committee score, Tegner activity scale, and range of motion showed no significant differences between the groups. The mean thickness of anteromedial graft was reduced by 10.3% and that of the posterolateral graft was reduced by 11.1% from the original graft thickness evaluated by magnetic resonance imaging. No new meniscal tears were found either group; however, cartilage damage occurred in the double-tunnel group at 39.3%, and this rate was significantly higher than that in the single-tunnel group (10.0%).

CONCLUSION

Single femoral, single tibial tunnel anatomic double-bundle ACL reconstruction has the same effectiveness as the double femoral, double tibial tunnel in restoring the knee's stability and functions.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion:" A Randomized Clinical Trial

BACKGROUND

The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction.

PURPOSE

This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft.

MATERIALS AND METHODS

One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score.

RESULTS

Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain.

CONCLUSION

There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.