A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction

BACKGROUND: Bone-patellar tendon-bone graft has been the most commonly used graft material in anterior cruciate reconstructions, but there has been increasing use of hamstring tendon grafts. However, no existing clinical studies show adequate support for the choice of one graft over the other. HYPOTHESIS: Hamstring tendons are equally as good as patellar tendon in anterior cruciate ligament reconstructions. STUDY DESIGN: Prospective randomized clinical trial. METHODS: Ninety-nine patients with laxity caused by a torn anterior cruciate ligament underwent arthroscopically assisted reconstruction with graft randomization according to their birth year. Grafts were either bone-patellar tendon-bone with metal interference screw fixation or double-looped hamstring tendons with metal plate fixation. There were no significant differences between the two groups preoperatively or at operation. Standard rehabilitation included immediate postoperative mobilization without a knee brace, protected weightbearing for 2 weeks, and return to full activity at 6 to 12 months. RESULTS: Forty-three patients in the patellar tendon group and 46 patients in the hamstring tendon group were available for clinical evaluation at a minimum of 21 months after surgery. No statistically significant differences were seen with respect to clinical and instrumented laxity testing, International Knee Documentation Committee Score ratings, isokinetic muscle torque measurements, and Kujala patellofemoral, Lysholm, and Tegner scores. CONCLUSION: Equal results were seen for patellar and hamstring tendon autograft anterior cruciate ligament reconstructions at 2 years after surgery. Both techniques seem to improve patients' performance.     

Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts

Despite the higher incidence of anterior cruciate ligament (ACL) injuries in female than in male athletes few authors have studied the effects of gender on the outcome of ACL reconstruction. This prospective study compared the results of ACL reconstruction using the patellar tendon and hamstring techniques in men and women. We prospectively followed 80 comparable athletes (46 males, 32 females) from a population of 287 patients operated on at our institution for ACL reconstruction using either patellar tendon or hamstring graft. There were 26 males and 14 females in the patellar tendon group, and 22 males and 18 females in the hamstring group. All patients were operated on by the same surgeon within 6 months from injury and underwent the same rehabilitation program at the same center. After an average of 36 months the patients were assessed by clinical evaluation, computerized knee laxity analysis, and isokinetic and functional strength tests; standard knee scores were also used. Among patellar tendon patients there were no significant differences between males and females regarding knee evaluation form, laxity, or isokinetic and functional tests. Females in the hamstring group had significantly greater laxity, and isokinetic tests at 1 year revealed a significantly higher deficit of peak torque at 60°/s in flexion and extension. We suggest further studies on the clinical significance of these findings particularly on their possible ramifications in the areas of return to sports and rehabilitation of female athletes     

Anterior cruciate ligament reconstruction in females: a comparison of hamstring tendon and patellar tendon autografts

This study compared hamstring (HS) and patellar tendon (PT) anterior cruciate ligament (ACL) reconstruction in females. Sixty-five patients (43 HS, 22 PT) were evaluated at a mean 3.8-year postoperatively. Evaluation included IKDC 2000, SF-36, Cincinnati sports activity scores, anterior knee pain (AKP), kneeling pain, range of motion and anterior knee laxity. One PT patient sustained a traumatic graft rupture. There were no differences between the two grafts in terms of anterior knee laxity or IKDC scores. The HS group had higher sports activity scores and higher scores on the Physical Functioning and General Health subscales of the SF-36. Despite no difference in AKP, there was greater kneeling pain in the PT patients, who also had greater extension deficits. Both HS and PT are satisfactory ACL grafts in females, but HS grafts were associated with less morbidity, greater return to preinjury level of activity and higher quality of life scores.     

A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up

BACKGROUND: There are still controversies about graft selection for primary anterior cruciate ligament reconstruction. Prospective randomized long-term studies are needed to determine the differences between the materials. HYPOTHESIS: Five years after anterior cruciate ligament reconstruction, there is a difference between hamstring and patellar tendon grafts in development of degenerative knee joint disease. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: From June 1999 to March 2000, 64 patients were included in this prospective study. A single surgeon performed primary arthroscopically assisted anterior cruciate ligament reconstruction in an alternating sequence. In 32 patients, anterior cruciate ligament reconstruction was performed with hamstring tendon autograft, whereas in the other 32 patients, anterior cruciate ligament reconstruction was performed with patellar tendon autograft. RESULTS: At the 5-year follow-up, no statistically significant differences were seen with respect to the Lysholm score, clinical and KT-2000 arthrometer laxity testing, anterior knee pain, single-legged hop test, or International Knee Documentation Committee classification results; 23 patients (82%) in the hamstring tendon group and 23 patients (88%) in the patellar tendon group returned to their preinjury activity levels. Graft rupture occurred in 2 patients from the hamstring tendon group (7%) and in 2 patients from the patellar tendon group (8%). Grade B abnormal radiographic findings were seen in 50% (13/26) of patients in the patellar tendon group and in 17% (5/28) of patients in the hamstring tendon group (P = .012). CONCLUSION: Both hamstring and patellar tendon grafts provided good subjective outcomes and objective stability at 5 years. No significant differences in the rate of graft failure were identified. Patients with patellar tendon grafts had a greater prevalence of osteoarthritis at 5 years after surgery.     

ACL reconstruction: patellar tendon versus hamstring grafts—economical aspects

The aim of the present investigation was to compare the costs for the use of patellar tendon versus hamstring tendons as grafts for anterior cruciate ligament (ACL) reconstruction including the different fixation methods. The background is that during recent years there has been a dramatic shift from patellar tendon to hamstring tendons in ACL reconstructions in Sweden. All our patients with ACL reconstructions performed during 1 year (2004) were included. Knee joints numbering 440 in 439 patients were primary ACL reconstructions. A hamstring graft was used in 345 knee joints (78.4%) and a patellar tendon graft in 95 (21.6%) of the patients (Table 2). On average 34 (SD 12.9; range 14–63) ACL reconstructions per surgeon were performed by a total of 14 surgeons. The average cost for patellar tendon procedure was 197 € compared to 436 € for the hamstring procedure. Mean time for surgery in primary reconstructions was 11.5 min shorter (P<0.001) for patellar tendon reconstructions (71.3±31 min) compared to hamstring reconstructions (83.2±27 min). This means a difference in cost of 90 €. The total additional cost (fixation and surgery time) for the hamstring method compared to the patellar tendon method was on an average 329 €. From a strict economic point of view we therefore recommend or at least consider the use of the patellar tendon as a graft in ACL reconstructions.     

Patellar tendon length after anterior cruciate ligament reconstruction: a comparative magnetic resonance imaging study between patellar and hamstring tendon autografts

Patellar tendon shortening after anterior cruciate ligament reconstruction may be associated with anterior knee pain or patellofemoral arthritis. The present study was designed to compare postoperative changes in patellar tendon length after anterior cruciate ligament reconstruction between patellar tendon and hamstring tendon autograft. Magnetic resonance images of both knees (operated and healthy) and functional outcome were documented at least 1 year postoperatively in 16 patellar tendon harvested patients and in 32 hamstrings harvested patients. Patellar tendon length, patella length and Insall–Salvati ratio were measured. The operated knee values were compared to the respective values of the non-operated control knees. A significant 4.2 mm or 9.7% patellar tendon shortening in patellar tendon group and a non-significant 1.14 mm or 2.6% shortening in hamstrings group was detected. No significant difference was detected in terms of major shortening—patella baja—(6% for the patellar tendon group vs. 0% for the hamsting group). There was no significant difference in anterior knee problems between the two groups as evidenced by the Shelbourne score (94 for the patellar tendon group vs. 98 for the hamsting group). Harvesting of the patellar tendon for anterior cruciate ligament reconstruction resulted in a significant shortening of the remaining tendon. In contrast harvesting of the hamstring tendons did not affect significantly the patellar tendon length. However, the incidence of patella baja and overall functional outcome was not significantly different between the two groups. Paper presented at the 12th ESSKA 2000 Congress, Innsbruck, Austria, 2006 and also presented at the 5th Biennial ISAKOS Congress, Hollywood, FL, USA, 2005.     

A 2-year follow-up of rehabilitation after ACL reconstruction using patellar tendon or hamstring tendon grafts: a prospective randomised outcome study

Sixty-eight patients were clinically evaluated preoperatively, 3, 5, 7, 9 months, 1 and 2 years after ACL reconstruction, 34 with patellar tendon graft, 34 with hamstring graft. Outcome regarding graft choice and anterior knee laxity (P = 0.04) was in favour of patellar tendon graft. Hamstring graft led to a larger laxity, 2.4 mm compared with patellar tendon graft, 1.3 mm at 1 year and 2.5 mm and 1.5 mm, respectively, at 2 years (P = 0.05). There was a significant difference in rotational knee stability in favour of the patellar tendon graft at all test occasions but 9 months. A general effect regarding graft choice and muscle torque was found at 90°/s for quadriceps (P = 0.03) and hamstrings (P ≤ 0.0001) and at 230°/s for hamstrings (P ≤ 0.0001). No treatment effect regarding graft choice and one-leg hop test, postural sway or knee function was found. No group differences in anterior knee pain were found at any of the test occasions but 2 years in favour of hamstring graft compared to patellar tendon graft (P = 0.04). Patellar tendon graft resulted in higher activity level than hamstring graft at all test occasions but 1 year (P = 0.01). Patellar tendon ACL reconstruction led to more stable knees with less anterior knee laxity and less rotational instability than hamstring ACL reconstruction. Hamstring graft patients had not reached preoperative level in hamstring torque even 2 years after ACL reconstruction. Athletes with patellar tendon graft returned to sports earlier and at a higher level than those with hamstring graft.     

The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique

In this study, mid to long-term results of anterior cruciate ligament reconstruction with hamstring tendons and Transfix technique were evaluated. Anterior cruciate ligament (ACL) reconstruction with four-strand hamstring tendon was performed with Transfix technique on 271 (198 males, 73 females; mean age 25.7; 17–52) patients with anterior cruciate ligament ruptures. The patients were followed up with clinical examination, Lysholm and Tegner activity scales, IKDC scoring system, KT-1000 test and radiological examination. The mean follow-up period was 82 (48–100) months; 204 (75%) patients had no subjective complaints. According to the KT-1000 test, only 14 (5%) patients had more than 5 mm laxity postoperatively, whereas, 161 (59%) patients had more than 5 mm laxity preoperatively. In addition to this, only 19 (7%) patients had Lysholm scores less than 80 postoperatively, whereas 154 (57%) patients scored less than 80 preoperatively. When compared with Tegner activity scale, 189 (70%) patients scored <6 preoperatively and only 24 (8%) postoperatively; 78 (29%) patients scored D preoperatively and only 5 (2%) patients scored D postoperatively on the basis of the IKDC scoring system. Our functional results were found to be satisfactory in more than 90% of patients. Commonly seen problems in ACL reconstruction such as inaccurate graft placement and tunnel widening were found to be consistent with the values in relevant literature. However, we demonstrated that the functional results and the stability of the knee were not related with tunnel widening. This study concludes that the reconstruction of ACL with hamstring tendons and the Transfix technique is reasonably successful, safe and causes low morbidity. Furthermore, we believe that proper graft preparation, accurate tunnel placement, notch-plasty, fixation and rehabilitation program are all as important as the choice of graft and fixation material.     

Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study

The purpose of the present investigation was to evaluate physical outcome after anterior cruciate ligament (ACL) reconstruction with early versus late initiation of open kinetic chain (OKC) exercises for the quadriceps in patients operated on either patellar tendon or hamstring grafts. Sixty-eight patients, 36 males and 32 females, with either patellar tendon graft (34 patients) or hamstring graft (34 patients) were enrolled in this study. All patients were randomly allocated to either early (the 4th postoperative week) or late (the 12th postoperative week) start of OKC exercises for the quadriceps, resulting in four subgroups: patellar tendon reconstruction, early start (P4) or late start (P12) of OKC quadriceps exercises, hamstring tendon reconstruction, early start (H4) or late start (H12) of quadriceps OKC exercises. Prior to surgery and 3, 5 and 7 months later, assessments of range of motion (goniometer), anterior knee laxity (KT-1000), postural sway (KAT 2000), thigh muscle torques (Kin–Com dynamometer) and anterior knee pain (anterior knee pain score) were evaluated. No significant group differences were found in terms of range of motion 3, 5 and 7 months postoperatively. The H4 group showed a significantly higher mean difference of laxity over time of 1.0 mm (CI: 0.18–1.86) than the P4 group (P = 0.04). Within the same type of surgery, the H4 against the H12, the mean difference over time was 1.2 mm (0.37–2.1) higher in the H4 group than in the H12 group (P = 0.01). There were no significant group differences in terms of postural sway or anterior knee pain at the different test occasions. Significant differences in trends (changes over time) were found when comparing the four groups, for both quadriceps muscle torques (P < 0.001) and hamstring muscle torques (P < 0.001). All groups, except the P4 group, reached preoperative values of quadriceps muscle torques at the 7 months follow-up. In the H4 and the H12 groups, significantly lower hamstring muscle torques at the 7 months follow-up compared with preoperative values were found. In conclusion, early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity in comparison with both late start and with early and late start after bone–patellar tendon–bone ACL reconstruction. Furthermore, the early introduction of OKC exercises for quadriceps did not influence quadriceps muscle torques neither in patients operated on patellar tendon nor hamstring tendon grafts. On the contrary, it appears as if the choice of graft affected the strength of the specific muscle more than the type of exercises performed. Our results could not determine the appropriate time for starting OKC quadriceps exercises for patients who have undergone ACL reconstruction with hamstring tendon graft. Future studies of long-term results of anterior knee laxity and functional outcome are needed.     

A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: differences and similarities

BACKGROUND: For arthroscopic anterior cruciate ligament reconstruction, the most commonly used graft constructs are either the hamstring tendon or patellar tendon. Well-controlled, long-term studies are needed to determine the differences between the 2 materials. HYPOTHESIS: There is a difference between hamstring and patellar tendon grafts in the clinical results of anterior cruciate ligament reconstructions at 7 years. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Two groups of 90 patients each, consecutively treated with hamstring or patellar tendon grafts, were followed and assessed at 1, 2, 5, and 7 years after surgery. RESULTS: At the 7-year review, abnormal radiographic findings were seen in 45% (24/53) of the patellar tendon group and in 14% (7/51) of the hamstring tendon group (P = .002). Although there was no significant difference between the groups in extension deficit (P = .22), the percentage of patients with an extension deficit increased significantly in the patellar tendon group from 8% at 1 year to 25% at 7 years (P = .02). No significant change was seen in the hamstring tendon group over time (P = .20). There was no significant difference in laxity between the groups on Lachman (P = .44), pivot-shift (P = .39), or instrumented (P = .44) testing. Graft rupture occurred in 4 patients from the patellar tendon group and in 9 patients from the hamstring tendon group (P = .15). Both autografts gave excellent subjective results, as evidenced by the International Knee Documentation Committee evaluation and Lysholm knee scores at 7 years. CONCLUSIONS: Both hamstring and patellar tendon grafts provided good subjective outcomes and objective stability at 7 years. No significant differences in the rate of graft rupture or contralateral anterior cruciate ligament rupture were identified. Patients with patellar tendon grafts had a greater prevalence of osteoarthritis at 7 years after surgery; therefore, the authors preferred hamstring tendons as the primary graft choice in anterior cruciate ligament reconstructions.     

Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts

Existing clinical studies have not proven which graft is to be preferred in anterior cruciate ligament (ACL) reconstruction. In recent years, bone-patellar tendon-bone and hamstring tendons have been the most frequently used graft types. Muscle strength deficit is one of the consequences after ACL reconstruction. The aim of this study was to evaluate possible differences in hamstring and quadriceps muscle strength and knee function 5 years after ACL reconstruction between the BPTB and the STG groups. The study group consisted of 288 patients (132 women, 156 men) with a unilateral ACL rupture who had received a BPTB (175 patients) or STG (113 patients) ACL reconstruction. Lower extremity concentric isokinetic peak extension and flexion torques were assessed at the angular velocities of 60°/s and 180°/s. The International Knee Documentation Committee (IKDC), the Tegner activity level, the Lysholm knee and the Kujala patellofemoral scores were also collected. Isokinetic quadriceps peak torque (percentage of the contralateral side) was 3.9% higher in the STG group than in the BPTB group at the velocity of 60°/s and 3.2% higher at the velocity of 180°/s and the isokinetic hamstring peak torque 2% higher in the BPTB group than in the STG group at the velocity of 60°/s and 2.5% higher at the velocity of 180°/s. In both groups the subjects had weaker quadriceps and hamstring muscle strength in the injured extremity compared with the uninjured one. In the single-leg hop test (according to the IKDC recommendations) there was a statistically significant difference (P = 0.040) between the groups. In the STG group, 68% of the patients had the single-leg hop ratio (injured vs. uninjured extremity) ≥90%, 31% of the patients 75–89% and 1% of the patients <75%, while in the BPTB group the corresponding percentages were 72, 21 and 7%. However, no statistically significant differences in clinical outcome were found between the groups as determined by the IKDC, Tegner activity level, Lysholm knee and Kujala patellofemoral scores.     

The knee adduction moment in hamstring and patellar tendon anterior cruciate ligament reconstructed knees

Purpose

The external knee adduction moment during gait has previously been associated with knee osteoarthritis, and although it has been shown to be greater following anterior cruciate ligament (ACL) reconstruction surgery compared to a control group, it has not been compared between different graft types. Given that the incidence of radiographic knee osteoarthritis appears to be greater following patellar tendon compared to hamstring tendon ACL reconstruction, this study tested the hypothesis that the knee adduction moment would also be increased following patellar tendon ACL reconstruction.

Methods

In 48 male participants (16 patellar tendon graft, 16 hamstring graft and 16 controls), the external knee adduction moment was measured during level walking in a gait laboratory at mean of 10?months after surgery.

Results

There was no difference in the knee adduction moment between the hamstring and patellar tendon groups, and both patient groups had a significantly reduced knee adduction moment compared to the control group. In the hamstring group, the smaller adduction moment was associated with the patients walking with less knee varus whereas in the patellar tendon group, the smaller moment was associated with the patients walking with a decreased vertical ground reaction force.

Conclusions

These results indicate that in male patients during the early stages of recovery from ACL reconstruction, the knee adduction moment is not greater than controls for either hamstring or patellar tendon graft types. Although the knee adduction moment was similar between the two graft types, the overall magnitude of the moment was influenced by different biomechanical factors.

Level of evidence

III.     

Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit

The most common graft in anterior cruciate ligament (ACL) surgery involves using the central one-third of the patellar tendon. Knowledge concerning the postoperative disability after harvesting the patellar tendon is, however, limited. The aim of this study was to evaluate the impact patellar tendon suture and bone grafting of the patellar bone defect might have in terms of functional outcome and patellofemoral pain after harvesting the bone-tendon-bone graft, compared with leaving the harvested site non-sutured and non-grafted. Sixty patients, scheduled for arthroscopically assisted ACL reconstruction, were randomly allocated to two groups. In group I, suture of the patellar tendon and bone grafting of the patellar defect were performed. In group II, the tendon gap and the patellar defect were left open. Preoperatively, there was no significant difference between the groups when comparing objective knee stability, as measured with a KT-1000 laxity meter, Lysholm score, Tegner activity level, IKDC score, or patellofemoral pain score. Both groups had a significantly improved Lysholm score at the 2-year follow-up, without any difference between them. Tegner's activity level was significantly lower at follow-up, compared with the pre-injury level in both groups. The patellofemoral pain score improved significantly after the reconstruction, without any difference between the groups. Ultrasonography did not reveal any difference between the groups in terms of healing of the tendon gap. This study revealed no differences in donor site morbidity, functional outcome, patellofemoral pain score or knee joint stability between the two treatment groups. The conclusion is that suture of the patellar tendon and bone grafting of the patellar defect do not improve the functional results or reduce donor site morbidity after arthroscopically assisted ACL. Received: 17 December 1996 Accepted: 30 July 1997     

A five-year comparison of patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the anterior cruciate ligament

BACKGROUND: The choice of graft material for anterior cruciate ligament reconstruction is believed to play a major role in outcome, but most comparisons of graft choice have not been well controlled. HYPOTHESIS: The choice of graft material (patellar tendon or hamstring tendon) does affect clinical outcome after anterior cruciate ligament reconstruction. STUDY DESIGN: Prospective, nonrandomized clinical trial. METHODS: Two groups of 90 patients each were followed for a minimum of 5 years. RESULTS: International Knee Documentation Committee assessment revealed that more than 85% of each group had an overall score of A or B at all follow-up intervals. The median Lysholm knee score was greater than 90 for both groups at 2 and 5 years. Instrumented testing revealed no significant difference between the two groups beyond 3 years. Thirty-one percent of the patellar tendon group (25) had a fixed flexion deformity and 19% of the hamstring tendon group (14) had fixed flexion deformity at 5 years. Radiologic assessment revealed early osteoarthritic changes in 4% of the hamstring tendon group (2) and in 18% of the patellar tendon group (11) at 5 years. CONCLUSIONS: Arthroscopic reconstruction with either graft results in a similar surgical outcome, reliably restoring knee stability over a 5-year period; however, patients with patellar tendon grafts are at greater risk of developing early signs of osteoarthritis.     

Post-operative use of knee brace in bone-tendon-bone patellar tendon anterior cruciate ligament reconstruction: 5-year follow-up results of a randomized prospective study

Sixty patients were prospectively randomized to brace and no-brace groups after bone-tendon-bone patellar tendon anterior cruciate ligament (ACL) reconstruction. The brace group wore a rehabilitation knee brace for 12 weeks post-operatively, while the no-brace group was mobilized immediately, and crutches were discarded 2 weeks post-operatively. The groups were comparable with respect to age, gender, time from injury to surgery and concomitant injuries. There were no differences either pre-operatively or 5 years post-operatively (80% of patients reviewed) between the groups in terms of the knee score (Lysholm), activity level (Tegner), degree of laxity or isokinetic peak muscle torque. Thus it appears that knee braces are not needed in the post-operative rehabilitation after ACL reconstruction with the patellar tendon graft.     

Preconditioning patellar tendon autografts in arthroscopic anterior cruciate ligament reconstruction: a prospective randomized study

This prospective randomized evaluated the effect of preconditioning patellar tendon autografts before implantation and fixation during anterior cruciate ligament (ACL) reconstruction. Fifty-three patients with a unilateral ACL rupture were included in the study. One group of patients had their patellar tendon autograft preconditioned by passive stretching at a constant load of 39 N for 10 min immediately prior to implantation (group P). The other group underwent no preconditioning before the implantation of the graft (group NP). The follow-up examination was performed by independent observers after 26 months (23-29) in group P and after 25 months (23-30) in group NP (n.s.). At follow-up the KT-1000 laxity test revealed a total side-to-side difference of 2.5 mm (-1.5 to +8.5) in group P and 3.0 mm (-7 to +6.5) in group NP (n.s.). The Lysholm score was 86 points (47-100) in group P and 94 points (44-100) in group NP (n.s.). The Tegner activity level was 6 (2-9) in group P and 7 (3-9) in group NP (n.s.). There was no significant difference between the study groups regarding IKDC classification. Patients who underwent ACL reconstruction using a preconditioned patellar tendon autograft had no advantages in terms of restoration of laxity or clinical outcome at 2-year follow-up.     

A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction

BACKGROUND: Patellar and hamstring tendon autografts are the most frequently used graft types for anterior cruciate ligament reconstruction, but few direct comparisons of outcomes have been published. HYPOTHESIS: There is no difference in outcome between the two types of reconstruction. STUDY DESIGN: Prospective randomized clinical trial. METHODS: After isolated anterior cruciate ligament rupture, 65 patients were randomized to receive either a patellar tendon or a four-strand hamstring tendon graft reconstruction, and results were reviewed at 4, 8, 12, 24, and 36 months. RESULTS: Pain on kneeling was more common and extension deficits were greater in the patellar tendon group. There were greater quadriceps peak torque deficits in the patellar tendon group at 4 and 8 months but not thereafter. In the hamstring tendon group, active flexion deficits were greater from 8 to 24 months, and KT-1000 arthrometer side-to-side differences in anterior knee laxity at 134 N were greater. Cincinnati knee scores, International Knee Documentation Committee ratings, and rates of return to preinjury activity levels were not significantly different between the two groups. CONCLUSIONS: Both grafts resulted in satisfactory functional outcomes but with increased morbidity in the patellar tendon group and increased knee laxity and radiographic femoral tunnel widening in the hamstring tendon group.     

Arthroscopic anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft

Tendon–bone incorporation of a tendon graft within the bone tunnel is of priority concern when using for anterior cruciate ligament (ACL) reconstruction. Superior healing process and stronger healing strength can be achieved when periosteum is sutured on the tendon inserted into a bone tunnel. We applied this idea to ACL reconstruction for enhancing tendon graft–bone tunnel healing. This is a prospective clinical outcome study with this surgical technique at minimal 2 years follow-up. Periosteum-enveloping hamstring tendon graft has been used in 68 patients. Data from 62 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of Lachman and anterior drawer test with a positive pivot-shift test. Clinical assessments included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented testing, thigh muscle assessment, and radiographic evaluation. The median Lysholm knee score was 59 (40–70) and 94 (60–100) points (P<0.01) before and after surgery. After reconstruction, 81% of patients were able to return to moderate or strenuous activity. Four (6%) patients were found to exhibit grade 2 or more ligament laxity. Complete range of motion could be achieved in 86% of patients. Three patients (5%) had positive pivot shift. Finally, 92% of patients were assessed as normal or nearly normal rating by IKDC guideline. Bone tunnels enlargement of more than 1 mm was identified in 5% of femoral tunnels and 6% of tibial tunnels. The study shows that a satisfactory result can be achieved with the periosteum-enveloping hamstring tendon graft in ACL reconstruction. Periosteum can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting. Besides the potential for improving tendon–bone healing, enveloped periosteum may help to seal the intra-articular tunnel opening in the early postoperative period, and thus avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be reduced.     

A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction

Seventy patients with patellar tendon or hamstring tendon autografts for single-incision anterior cruciate ligament reconstruction were evaluated at least 2 years after surgery. All reconstructions were performed by the same surgeon, and metal interference screws were used for fixation of all grafts. No significant differences were noted between groups for Lysholm score, reduction in activity, KT-1000 arthrometer findings, quadriceps muscle size, return to sports, or ability to jump and do hard cuts and pivots. Significantly more patients in the patellar tendon group had patellofemoral pain at 6 months after surgery than did the hamstring tendon patients (48% versus 20%), and at last follow-up the incidence of patellofemoral pain was 42% and 20%, respectively. Fourteen patients in the patellar tendon group and seven in the hamstring tendon group had loss of motion (approximately 5 degrees ). Four patients (two in each group) had treatment failures and their results were not included in the clinical examination data. At 2 years' follow-up, 97% of patients with patellar tendon grafts and 100% of patients with hamstring tendon grafts rated their results as good or excellent. We found that hamstring tendon grafts performed similarly to patellar tendon grafts, although fewer patients in the hamstring tendon group had patellofemoral pain and loss of motion.     

Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts

BACKGROUND: The best choice of graft tissue for use in anterior cruciate ligament reconstruction has been the subject of debate. HYPOTHESIS: Anterior cruciate ligament reconstruction with patellar tendon autograft leads to greater knee stability than reconstruction with hamstring tendon autograft. STUDY DESIGN: Metaanalysis. METHODS: A Medline search identified articles published from January 1966 to May 2000 describing arthroscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring tendon autograft and with a minimum patient follow-up of 24 months. RESULTS: There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%). CONCLUSIONS: Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain.