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Document Title: Spindler-AJSM-Dec04.shtml
Article Title: Clinical Sports Medicine Update -- Anterior Cruciate Ligament Reconstruction Autograft Choice: Bone-Tendon-Bone Versus Hamstring -- Does It Really Matter? A Systematic Review
Authors: Kurt P. Spindler, MD, John E. Kuhn, MD, Kevin Blake Freedman, MD, Charles E. Matthews, PhD, Robert S. Dittus, MD, MPH and Frank E. Harrell, Jr, PhD
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: December 2004
Volume 32, pages 1986-1995
Keywords: anterior cruciate ligament reconstruction, patellar-tendon autograft bone-tendon-bone, hamstring autograft, comparison, meta-analysis, evidence-based medicine.
(Reference-denoting numbers appear in the same font and point size as the document text. This article contains tables, but no figures.)
Comments: This exhaustive review of published research concludes that graft choice is not the primary factor in determing ACL-reconstruction success. It adds more fuel to the age-old patellar-tendon-versus-hamstring autograft debate (despite the generally accepted figures of 95% success rate for patellar-tendon and 90% success rate for hamstring autograft; see, for example, Noyes-AJSM-Jul97.shtml). Looking at the nuts-and-bolts biomechanics of ACL grafting, the patellar-tendon autograft has the undeniable and unique advantage of secure bone-to-bone healing (as a consequence of having bone plugs at both ends). Meanwhile, the hamstring autograft has the advantage of no discomfort while kneeling, but the drawback of rather high rates of bone-tunnel widening and other worrisome concerns. Another drawback of the hamstring autograft is that it compromises the strength of the hamstring group...an especially serious concern for females, given that females tend to have proportionally weak hamstrings to begin with. (Articles on the female proclivity to ACL injuries can be found here.) However, it should be kept in mind that hamstring-graft-anchorage methods have improved, thus alleviating the "bungee-cord effect" which plagued earlier hamstring-graft-anchorage schemes (i.e. the graft was anchored only at the ends of the tunnels furthest from the joint, thus allowing it to stretch along its entire length and therefore move inside the tunnel; this prevented proper healing). In the end, the choice of graft is something which the patient should make after having an in-depth discussion with his/her orthopedic surgeon.
ABSTRACT
Anterior cruciate ligament graft choice is controversial, with no evidence-based consensus available to guide decision making. The study design was evidence-based medicine systematic review of randomized controlled trials evaluating patellar tendon versus hamstring tendon autografts. A literature review identified 9 randomized controlled trials comparing patellar tendon and hamstring tendon autografts. An evidence-based systematic review was performed. Objective and subjective outcomes of interest included surgical technique, rehabilitation, instrumented laxity, isokinetic strength, patellofemoral pain, return to preinjury activity, and Tegner, Lysholm, Cincinnati, and International Knee Documentation Committee–1991 scores. Additional surgery, graft failure, and complications were reviewed. Slight increased laxity on arthrometer testing was seen in the hamstring population in 3 of 7 studies. Pain with kneeling was greater for the patellar tendon population in 4 of 4 studies. Only 1 of 9 studies showed increased anterior knee pain in the patellar tendon group. Frequency of additional surgery seemed to be related to the fixation method and not graft type. No study reported a significant difference in graft failure between patellar tendon and hamstring tendon autografts. Objective differences (range of motion, isokinetic strength, arthrometer testing) were not detected between groups in the majority of studies, suggesting that their sensitivity to detect clinical outcomes may be limited. Increased kneeling pain in the patellar tendon group was seen consistently in the studies evaluated. Subjective differences in anterior knee pain or return-to-activity level were not consistently observed in these studies. With numbers available, failure rates were not significantly different between groups. These findings suggest that graft type may not be the primary determinant for successful outcomes after anterior cruciate ligament surgery.
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