Editorial Commentary: Addition of the Sartorius Tendon to Small-Diameter Hamstring Anterior Cruciate Ligament Autografts May Improve Outcomes in Pediatric and Revision Cases

Graft selection in anterior cruciate ligament reconstruction can have a pivotal role in a successful outcome. One of the major concerns with hamstring autograft is the variability of the diameter of each tendon, and grafts with a diameter of less than 8 mm may result in an increased failure rate. The addition of the sartorius tendon as a fifth strand in small-diameter hamstring autografts increases graft strength and diameter. This may improve outcomes in pediatric and revision cases.     

Editorial Commentary: Anterior Cruciate Ligament Hamstring Autografts Should Be Avoided in Patients Younger Than 25 Years Old: Autograft–Allograft Hybrids Remain Controversial

Some studies have reported no difference between autograft and hybrid anterior cruciate ligament reconstructions. However, other studies have shown a significantly greater revision rate. Consequently, surgeons are reluctant to perform hybrid reconstructions in younger patients with diminutive hamstring autografts and have turned to other autograft graft sources (e.g., quadriceps tendon, patellar tendon). Until we can perform high-quality prospective studies that can definitively answer this question, we should consider avoiding autograft hamstring reconstructions in patients younger than 25 years old so that we are not faced with the dilemma of implanting an undersized autograft or a hybrid graft, as both may be at increased risk for failure.     

Editorial Commentary: With Appropriate Anterior Cruciate Ligament Graft Selection,All-Inside Reconstruction Results in Excellent Outcomes: Stay “Inside” and Be Cognizant of Hamstring Graft Diameter Expectations in Shorter Patients

All-inside anterior cruciate ligament (ACL) reconstruction is a minimally invasive and anatomic technique with predictably excellent results. The array of graft choices that exists for skilled arthroscopists include semitendinosis autograft with or without gracilis, quadriceps tendon autograft, and patellar tendon autograft and allograft. The advantages of all-inside ACL reconstruction include independent femoral socket creation and less pain compared with a full tibial tunnel in the early postoperative period. This is a technique that should not trump appropriate graft selection. It is expected that autografts will fare better in younger patients who participate in activities at greater risk for ACL injuries. Selection of a semitendinosis autograft results in predictably excellent results when graft diameters are 8 mm or greater. Quadrupling the semitendinosis and adding the gracilis when needed can provide sufficient graft diameter in many patients. However, caution should be taken when harvesting hamstring grafts from shorter patients. Semitendinosis tendons in such patients are sometimes not long enough to quadruple and can result in a diameters less than 8 mm even when the gracilis is added. With appropriate graft selection, staying “inside” for ACL reconstruction is expected to result in great objective and subjective outcomes for our patients.     

Small Size Autograft versus Large Size Allograft in Anterior Cruciate Ligament Reconstruction

BackgroundA small autograft diameter negatively affects functional outcomes, knee stability, and the risk of rerupture after anterior cruciate ligament (ACL) reconstruction, whereas the strength of allograft decreases over time. Therefore, it is not clear whether the use of smaller autografts or the use of larger allografts in ACL yields better results. The aim of this study was to compare the outcome of smaller autografts and larger allografts for ACL reconstruction.MethodsFifty-one patients who underwent ACL reconstruction with hamstring tendon autografts (size ≤ 8 mm) and 21 patients who underwent ACL reconstruction with allografts (size ≥ 10 mm) were included in our study. All patients underwent the same aggressive early postoperative rehabilitation program. There were no significant differences between the autograft and allograft groups regarding the preoperative patient age, sex, time from injury to surgery, and average follow-up time.ResultsThe mean diameter of the 4-stranded hamstring tendon grafts used as autografts was 7.48 ± 0.33 mm and the mean diameter of the allografts was 10.76 ± 0.67 mm. According to specific tests for the ACL (anterior drawer, Lachman, and pivot shift) and clinical evaluation tests (Lysholm knee scoring scale and International Knee Documentation Committee questionnaire), the final follow-up results were significantly better than the preoperative status in both autograft and allograft ACL reconstruction groups. Therefore, there were no significant differences between the autograft and allograft groups preoperatively and at the final follow-up.ConclusionsThe large size of the graft in ACL reconstruction has been reported to affect results positively. However, in our study, we could not find any significant differences between the smaller size autografts and larger size allografts in terms of inadequacy, rerupture, and final follow-up functional results. Although allografts were significantly larger than autografts, we did not have the positive effect of larger size grafts. Smaller size autografts were as effective as the larger size allografts.     

Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients

Background

Bone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) reconstruction. Existing clinical trials, registry studies, and meta-analyses offer conflicting opinions regarding the most favorable graft choice.

Questions/purposes

Which graft type for ACL reconstruction (bone-tendon-bone or hamstring) has a higher risk of (1) graft rupture and/or (2) graft laxity?

Methods

We performed a meta-analysis of randomized controlled trials (RCTs), prospective cohort studies, and high-quality national registry studies to compare the outcomes of primary ACL reconstruction with bone-tendon-bone autograft or hamstring autograft. Studies that compared these graft types were identified through a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, and the Cochrane Library). Two independent reviewers utilized the Jadad scale for RCT study quality and the Modified Coleman Methodology Score for prospective comparative and registry study quality. The included studies were analyzed for the primary outcome measure of graft rupture with or without revision ACL surgery. In surviving grafts, secondary outcomes of graft laxity were quantified by KT1000/2000? testing, a positive pivot shift test, and a positive Lachman test. Meta-analysis was performed with Review Manager. A total of 47,613 ACL reconstructions (39,768 bone-tendon-bone and 7845 hamstring) from 14 RCTs, 10 prospective comparative studies, and one high-quality national registry study were included in this meta-analysis. Mean age was 28 years in both groups. Sixty-three percent of patients in the bone-tendon-bone cohort were men versus 57% of patients in the hamstring cohort. Mean followup was 68 ± 55 months.

Results

Two hundred twelve of 7560 (2.80%) bone-tendon-bone grafts ruptured compared with 1123 of 39,510 (2.84%) in the hamstring group (odds ratio = 0.83, 95% confidence interval, 0.72-0.96; p = 0.01). The number needed to treat analysis found that 235 patients would need to be treated with a bone-tendon-bone graft over a hamstring tendon graft to prevent one graft rupture. Instrumented laxity analysis showed that 22% (318 of 1433) of patients in the bone-tendon-bone group had laxity compared with 18% (869 of 4783) in the hamstring tendon group (odds ratio = 0.86; p = 0.16). Pivot shift analysis showed a positive pivot shift in 19% (291 of 1508) of the bone-tendon-bone group compared with 17% (844 of 5062) in the hamstring group (odds ratio = 0.89; p = 0.51). Lachman testing showed a positive Lachman in 25% (71 of 280) of patients receiving bone-tendon-bone grafts compared with 25% (73 of 288) in the hamstring group (odds ratio = 0.96; p = 0.84).

Conclusions

In this meta-analysis of short- to mid-term followup after primary ACL reconstruction, hamstring autografts failed at a higher rate than bone-tendon-bone autografts. However, failure rates were low in each group, the difference observed was small, and we observed few differences between graft types in terms of laxity. Both graft types remain viable options for primary ACL reconstruction, and the difference in failure rate should be one part of a larger conversation with each individual patient about graft selection that should also include potential differences in donor site morbidity, complication rates, and patient-reported outcome measures. Continued prospective collection of patient data will be important going forward as we attempt to further characterize the potential differences in outcomes attributable to graft selection.

Level of Evidence

Level III, therapeutic study.

     

Prediction of hamstring tendon autograft diameter and length for anterior cruciate ligament reconstruction

The purpose of this study was to determine whether common physical measurements in patients undergoing anterior cruciate ligament (ACL) reconstruction with autologous hamstring tendon could be used to predict autograft length and diameter. One hundred nineteen consecutive patients undergoing hamstring autograft ACL reconstruction had these preoperative measurements taken: age, height, weight, bilateral leg length, and bilateral thigh girth 5 and 10 cm proximal to the superior pole of the patella. Correlations between these measurements and graft length and diameter were evaluated. There was a strong correlation between leg length and hamstring autograft length (r = .73, P<.001). Weight (r = .51, P<.001) and leg length (r = .42, P<.001) had only moderate correlations with graft diameter. All other correlations were weak. Regression analysis demonstrated that leg length can be used to predict hamstring autograft tendon length to within 20 mm and that weight can be used to predict graft diameter to within 1.2 mm using regression equations. In conclusion, several simple measurements correlate with doubled semitendinosus and gracilis tendon autograft length and diameter. This new information may prove useful to surgeons who want hamstring autografts of a certain diameter or of a long length.     

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,¹ and an objective failure rate of 13.7% has been reported for revision ACLR.² Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.     

Editorial Commentary: Large-Diameter Quadrupled Hamstring Autografts Are an Acceptable Option for National Collegiate Athletic Association Division I College Football Players: We Must Challenge Our Comfort Zone to Be Successful in the End Zone

The majority of surgeons caring for elite American football teams choose bone–patellar tendon–bone (BTB) autograft for anterior cruciate ligament reconstruction. As we strive to continue to improve currently favorable outcomes, we need to consider all options regarding graft choice, surgical technique, and postoperative rehabilitation. Advantages of BTB include an excellent track record, potential for faster incorporation with bone-to-bone healing. Disadvantages include risk of patellar fracture/tendon rupture and anterior knee pain. The pros of quadrupled hamstring (QH) graft include stronger graft (higher ultimate load to failure) and less anterior knee pain and stiffness, and the cons include loss of flexion/hamstring strength and slower healing in the tunnels. Several studies have shown that smaller grafts have higher failure rates, and recent research shows that QH grafts >9 mm had decreased risk of revision compared to BTB. We can now quadruple the semitendinosus tendon to provide elite athletes with even more robust grafts. Large-diameter QH autografts are an acceptable option for National Collegiate Athletic Association Division I college football players.     

Editorial Commentary: Goldilocks and the Three Grafts: Managing Tendon Harvest and Graft Length Problems in Autograft Anterior Cruciate Ligament Reconstruction

Autograft hamstring tendon harvest in anterior cruciate ligament (ACL) reconstruction can occasionally result in a graft length that is inadequate for creation of a robust ACL graft. Patients at risk for an abnormally short hamstring may also be high risk for ACL reinjury. Graft augmentation with allograft may be a suboptimal solution to this problem. Therefore, a reliable means for preoperative estimation of hamstring tendon length by magnetic resonance imaging measurement could avoid this pitfall. However, even with a reliable correlation between magnetic resonance imaging measurement and actual harvested tendon length, establishing a simple, clinically relevant threshold below which hamstring grafts should be avoided remains elusive. By contrast, all-soft-tissue quadriceps autograft avoids the potential length problems inherent to both bone tendon bone (graft–tunnel mismatch) and hamstring tendon grafts, but intermediate- and long-term outcome studies are still needed to validate all-soft-tissue quadriceps autograft in ACL reconstruction.     

Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Background Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone patellartendon bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts.

Methods We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bonepatellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis.

Results Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32-0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82-1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group.

Interpretation Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability.     

Editorial Commentary: Patellar Tendon or Hamstring: Which Kind of Anterior Cruciate Ligament Patient Are You?

The role of graft selection on clinical and functional outcomes following anterior cruciate ligament (ACL) reconstruction has gained significant attention in the orthopaedic sports medicine community in recent years. Bone–patellar tendon–bone (BPTB) and semitendinosus/gracilis hamstring tendon (HT) autografts are 2 of the most commonly used grafts, given their low failure rates, predictable outcomes, and ability to incorporate appropriately at the graft site. However, multiple studies have recently shown each of these graft options to have some potentially less-desirable characteristics in regards to outcomes in specific patient populations. More specifically, in 14- to 25-year-old athletes, HT autografts have been shown to result in decreased rotational stability, decreased return to sport rates, and increased graft failure rates. On the other hand, BPTB autografts can require a prolonged recovery period and have been associated with increased postoperative pain and long-term kneeling pain. HT and BPTB grafts are both excellent grafts; however, it is important to understand the differences in clinical and functional outcomes between these graft options for ACL reconstruction. The characteristics of the graft need to be considered and individualized for each patient who is being treated for an ACL injury.     

自体Hamstring腱重建前交叉韧带术后关节镜下再视观察

目的关节镜再视观察游离Hamstring腱重建前交叉韧带后在体内重塑与转归过程.方法关节镜下再视手术,观察关节镜下自体同侧游离Hamstring腱重建前交叉韧带33例.重建术至再视手术时间为2～36个月,平均11.9月.依据重建术至再视术的时间,替代腱按时段分组:1月～,4月～,7月～,10月～,13月～,18月～和25月～组.再视术重点观察评估了移植的Hamstring腱形状、色泽、张力、覆盖的滑漠组织和血管状况.结果再视关节镜下重建前交叉韧带的Hamstring腱随植入时间延长,其形态逐步向正常前交叉韧带重塑与转归;7月～组和此后各组的替代腱在关节镜视下表现为.一种几乎无滑膜和血管的灰白色粗壮的圆柱体,类似于正常的前交叉韧带组织,达到了在体内成熟的程度.结论自体游离多股Hamstring腱重建前交叉韧带术后具有良好早期存活,快速再血管化和重塑过程,其术后的重塑与成熟过程与自体髌腱的过程相似,但其在体内重塑与转归进程相对较快.     

Arthroscopy-assisted anterior cruciate ligament reconstruction with patellar tendon or hamstring autografts

Isolated ACL reconstructions were performed in 138 patients between 1994 and 1998. Patellar bone-patellar tendon-bone, and hamstring tendon autografts were used in 88 patients, and allografts were used in 50 patients. Eighty-eight knees of 88 patients with autograft reconstructions (17 female, 71 male) were included in this study and evaluation of the patients with allograft reconstruction reported separately. The mean age at the time of the operation was 32 years. All ACL reconstructions were performed arthroscopically. Twenty-seven bone-patellar tendon-bone, and 61 hamstring tendon autografts were used. The mean follow-up was 29 months. In the postoperative course the Lachman test was negative in 62 patients, 1+ in 22 patients, and 2+ in 4 patients. In 17 patients, anterior drawer sign were 1+ in comparison to the contralateral side. Pivot shift test was moderately positive only in 5 cases in the bone-patellar tendon-bone and hamstring tendon autograft groups postoperatively. There were 3 patients with subjective "giving way" symptoms. Second look arthroscopy revealed rupture of the neo-ligament. Arthroscopic washout and debridement were performed, and no revision ligamentoplasties were performed. Two of these patients improved with accelerated proprioceptive physical therapy, and one had to decrease his previous level of activity. There were no cases of arthrofibrosis, infection, or extension lag. Clinical results of patellar bone-tendon-bone and hamstring groups did not show any significant clinical difference. Avoiding the disturbance of the extensor mechanism of the knee is probably the most significant advantage of the hamstring autograft.     

Hamstring tendon autograft better than bone patellartendon bone autograft in ACL reconstruction A cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Background?Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone patellartendon bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts.

Methods?We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bonepatellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis.

Results?Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32–0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82–1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group.

Interpretation?Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability.     

Relationship between anthropometric measurements and hamstring autograft diameter in anterior cruciate ligament reconstruction

The role of anthropometric measurements in the prediction of hamstring autograft size remains unclear. In this internal review board - approved study, we evaluated medical records for patients receiving anterior cruciate ligament (ACL) reconstruction with hamstring autograft at our institution between 2006 and 2008. One hundred and thirty-two patients received hamstring autografts. Correlation coefficients and step-wise multiple linear regression analysis were used to determine the relationships between sex, age, height, body mass index (BMI), and hamstring graft diameter. Women had significantly smaller grafts than men (P < .00001). Twenty-four patients had grafts less than 7 mm in diameter and 18 of those patients were female. Age and BMI did not correlate with graft diameter in women. Height correlated to graft diameter in women (P = .002, R(2) = 0.14). Women shorter than 65 in had significantly smaller graft diameters (mean [SD], 6.94 [0.45] mm), than those women 65 in and taller (mean [SD], 7.20 0.49] mm; (P = .03). Age and height did not correlate with graft size in men. BMI greater than 25 kg/m(2) correlated with larger graft diameter, but BMI less than 18 kg/m(2) did not predict graft sizes less than 7 mm. Therefore, alternative graft options should be considered in women less than 65 in tall.     

双束双隧道6股腘绳肌腱解剖重建前交叉韧带

目的探讨双束双隧道6股腘绳肌腱重建前交叉韧带（ACL）的可行性及近期疗效。方法对28例ACL损伤患者行关节镜下ACL重建术。采用股骨胫骨双隧道建立前内侧束（AMB）及后外侧束（PLB）。分别将股薄肌腱、半腱肌腱编织成3股肌腱,用于重建PLB与AMB。AMB与PLB股骨端均用Endobutton钢板固定,胫骨端AMB用Bio-Intrafix固定,PLB用Milagro可吸收界面螺钉固定。结果 28例均获随访,时间12-24（19.54±3.84）个月。根据Lysholm膝关节功能评分：术前为18-60（34.79±12.53）分,术后1年为90-98（95.54±2.06）分,差异有统计学意议（t=26.51,P〈0.01）。结论双束双隧道6股腘绳肌腱重建ACL,手术操作简便,固定牢固,效果可靠。     

Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques,graft preparation,and different fixation methods

Rupture of the anterior cruciate ligament (ACL) is a common orthopedic injury. Various graft options are available for the reconstruction of ruptured ACL. Using the hamstring muscle as an autograft was first described in 1934, and it remains a commonly harvested graft for ACL reconstruction. Hamstring autografts can be harvested using the traditional anteromedial approach or the newer posteromedial technique. An isolated semitendinosus tendon can be used or combined with the gracilis tendon. There are numerous methods for graft fixation, such as intra-tunnel or extra-tunnel fixation. This comprehensive review discusses the different hamstring muscle harvesting techniques and graft preparation options and fixation methods. It provides a comprehensive overview for choosing the optimal surgical technique when treating patients.     

Editorial Commentary: Reduce the Failure Risk: A Challenge to Reduce the Risk of Using Hybrid Graft in Anterior Cruciate Ligament Reconstruction

Hybrid grafting (augmentation of small hamstring autografts with allograft tissue) is preferred by many surgeons for anterior cruciate ligament (ACL) reconstruction. Although a recent, well-conducted, systematic review reported no significant differences in failure risk between hybrid graft and autograft ACL reconstruction, a trend toward a greater failure risk using the hybrid graft existed in many of the included studies. Three potential causes of hybrid graft ACL reconstruction failure that are absent in autograft ACL reconstruction are different levels of graft revascularization and ligamentization, differences in the tendon-bone healing capacity between the allograft and autograft portions in the bone tunnel, and processing of the graft. Research advances in these areas will further reduce the failure risk of hybrid graft ACL reconstruction.     

自体髌腱与四股腘绳肌腱移植重建前交叉韧带安全性的Meta分析

目的 评价自体髌腱与4股腘绳肌腱移植关节镜下单束重建前交叉韧带(ACL)的安全性.方法 计算机检索CENTRAL、PubMed、EMBASE、中国生物医学文献数据库等,获取自体髌腱与4股腘绳肌腱移植重建ACL的随机对照试验(RCT),根据Cochrane图书馆推荐的RCT偏倚评估标准对纳入研究的方法学质量进行评估,并使用RevMan 5.0统计学软件对结果进行Meta分析,比较自体髌腱与4股腘绳肌腱移植重建ACL的移植失败率、伸膝缺失度、膝前痛等的差异.结果共纳入14篇文献,包括1232例患者.自体髌腱组与自体4股腘绳肌腱组的移植失败率在平均随访2～3年(RR=0.69,95%CI 0.34～1.38,P=0.29)、5年(RR=0.37,95%CI0.09～1.55,P=0.18)、10年(P=0.94)及合并后(RR=0.71,95%CI 0.39～1.31,P=0.28)差异均无统计学意义.两组伸膝缺失度≥5°的例数比较差异无统计学意义(RR=1.63,95%CI0.85～3.16,P=0.14).两组膝前痛随访2年差异有统计学意义(RR=2.04,95%CI 1.34～3.09,P=0.0008),而随访5年(RR=3.00,95%CI 0.92～9.79,P=0.07)及随访10年(P=0.737)差异均无统计学意义.两组膝跪痛或不适随访2年差异有统计学意义(RR=1.97,95%CI 1.01～3.85,P=0.05),随访5年(RR=1.51,95%CI 0.95～2.39,P=0.08)及随访10年(P=0.342)差异无统计学意义.结论自体髌腱与4股腘绳肌腱移植失败率及膝关节被动伸直缺失的发生率相似.自体髌腱移植随访早期(平均随访2～3年)膝前痛、膝跪痛或不适的发生率较高,但随着时间的延长(5～10年),两者趋于一致.

Abstract：

Objective To compare clinical outcomes of patellar tendon and 4-strand hamstring autografts in single-bundle endoscopic reconstruction of anterior cruciate ligament(ACL). Methods The digital databases(PubMed,Embase,Cochrane Central Register of Controlled Trials,CBM)were searched for randomized controlled trials (RCTs)comparing patellar tendon with hamstring autografts for reconstruction of ACL.In addition.the reference lists from related original studies and review articles were hand-searched.The Cochrane Collaboration's tool for assessing risk of bias and Cochrane collaboration's RevMan 5.0 software were used for assessing trial methodological quality and data analyses. Results Fourteen RCTs were included.There were 1232 participants who met inclusion criteria in all studies.Meta-analyses showed that no statisticallv significant differences were found in graft failure rate after single-bundle reconstruction of the ACL at mean follow-ups of 2 to 3 years (RR=0.69,95%C/0.34 to 1.38,P=0.29,of 5 years (RR=0.37,95%CI 0.09 to 1.55,P=0.18),of 10 years(P=0.94)or when 3 subgroups combined(RR=0.71,95%CI 0.39 t0 1.31.P=0.28).The diffe-rence in≥5°extensor deficit was not statistically significant between the 2 groups(RR=1.63.95%CI 0.85 to 3.16,P=0.14).Anterior knee pain and kneeling pain or discomfort showed significantlv differences between the 2 groups at a mean follow-up of 2 years(P<0.05),but did not at follow-ups of 5 years and 10 years(P>0.05). Conclusions In single-bundle endoscopic ACL reconstruction.patellar tendon and 4-strand hamstring autografts have similar rates of graft failure and knee motion deficits.The patellar tendon autograft may have higher rates of anterior knee pain and kneeling pain or discomfort at an early stage after operation than the 4-strand hamstring autografi,but there may be no such differences on a long-term basis.     

Revision anterior cruciate ligament reconstruction with ipsi- or contralateral hamstring tendon grafts

Objectives

With the increasing number of primary anterior cruciate ligament (ACL) reconstructions, the need for revision ACL surgery has risen over the past few years. The purpose of the present study is to retrospectively compare the clinical outcome of ipsilateral versus contralateral hamstring tendon autografts for ACL revision surgery, specifically with regard to patient satisfaction, post-operative functional outcomes, and return to sports.

Methods

Between 2004 and 2011, 64 patients underwent ACL revision surgery. Forty-five were successfully recontacted and retrospectively reviewed at an average follow-up of 6.3 years. Twenty-two subjects underwent revision ACL reconstruction with ipsilateral autogenous hamstring tendon grafts; in 23 subjects contralateral hamstring were used for reconstruction. Clinical, arthrometric, and functional evaluations were performed. The Tegner activity level, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Subjective Knee Form were used. Objective evaluation included range of motion, Lachman test, pivot shift test and KT-1000 instrumented laxity testing.

Results

No major complications were reported. Follow-up examination showed that there were no significant differences in the IKDC and KOOS scores between the groups. No differences in anterior tibial translation as measured with KT-1000 arthrometer were reported between the groups, although there was a trend for more of the patients undergoing ipsilateral DGST reconstruction to have a glide on the pivot shift test. The percentage of patients returning to pre-injury level was high in both groups.

Conclusions

The use of contralateral hamstring tendon autografts for ACL revision surgery produced similar subjective and objective outcomes at 6-years follow-up compared to revision with ipsilateral hamstring tendon autografts. Patients undergoing revision surgery with contralateral autografts experienced a quicker return to sports compared to patients who underwent ipsilateral DGST revision surgery.