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     

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.     

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.     

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 ± 7.0 mm², while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm², showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm², almost equal to the value at the final follow-up (49.8 mm²) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.     

Graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction Intraoperative and cadaver measurement of the intra-articular graft length and the length of the patellar tendon

The results of a study conducted on 50 knees endoscopically reconstructed for an anterior cruciate ligament (ACL) lesion with a free bone-patellar tendon-bone graft and 9 cadaver knees are reported. The mean lengths of the patellar tendon (45.48 ± 4.71 mm) and intra-articular ACL graft (20.44 ± 1.98 mm) were measured in the operated knees. The mean length of the tibial bone tunnel (51.62 ± 2.60 mm) was also measured with a tibial guide at 55°. No statistically significant correlation was found between these three measurements. The length of the patellar tendon was weakly correlated with body height. Measurement of the tibial tunnel on the cadaver knees with increasing degrees of inclination revealed a mean length increase of 0.68 mm per degree (confidence limits: 0.49–0.86). Comparison between the tunnel lengths obtained with the guide and those measured with a Kirschner wire showed a mean difference of 2.3 mm. It is thus desirable to make the tunnel about 53 mm long to ensure excellent fixation of a 28 mm bone block with a 25 mm interference screw. Correct measurement of the anatomical structures involved is in any event an essential requirement for proper execution of the surgical technique. Received: 26 June 1997 Accepted: 12 November 1997     

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.     

Interference screw fixation of hamstring vs patellar tendon grafts for anterior cruciate ligament reconstruction

The present study was designed to investigate the fixation strength of a quadruple semitendinosus-gracilis graft compared with a middle-third bone-patellar tendon-bone graft using a new interference screw developed to fix hamstrings grafts for ACL reconstructions (RCI, Smith & Nephew Donjoy). Five pairs of human cadaveric knees from donors with a mean age of 43 (range 33–52) years were used. One knee of each pair was randomly allocated to be reconstructed on the femoral side with a semitendinosus-gracilis graft from the same donor using RCI screw fixation. As the control, the contralateral knee was correspondingly reconstructed with a bone-patellar tendon-bone graft using the same interference screw. The grafts were pulled out at a velocity of 30 mm/s by an axially applied load using a MTS machine. The mean (SD) failure load for the bone-patellar tendon-bone graft fixations was 505 (25) N, 110% stronger than the mean failure load for the semitendinosus-gracilis graft fixations, which was 240 (47) N (P = 0.003). The stiffness for the patellar tendon-bone graft fixations was 46 (11) N/mm, 120% stiffer than the semitendinosus-gracilis graft fixations, which was 22 (11) N/mm (P = 0.01). This study shows that the interference screw principle used for ACL reconstructions with hamstrings tendons is inferior to that for bone-patellar tendon-bone reconstructions although the screw was developed especially for soft-tissue fixation in bone tunnels. Received: 14 August 1996 Accepted: 25 September 1997     

Arthroscopic anterior cruciate ligament double-bundle reconstruction using hamstring tendon grafts-fixation with two interference screws: technical note

In this article, an original double-bundle anterior cruciate ligament reconstruction technique is described. The procedure is developed using hamstring tendon grafts while maintaining tibial osseous insertion. Two tibial tunnels are drilled and a simplified and precise outside-in double tunnel femoral drilling technique is utilized. The graft fixation is made using only two interference screws.     

Randomized prospective study of ACL reconstruction with interference screw fixation in patellar tendon autografts versus femoral metal plate suspension and tibial post fixation in hamstring tendon autografts: 5-year clinical and radiological follow-up results

Patellar tendon graft has been the most frequently used material in anterior cruciate ligament (ACL) reconstruction, but the hamstring tendons have been increasingly used as well; however, which graft is to be preferred is not adequately supported by existing clinical studies. In this prospective randomized clinical trial, the study hypothesis was that the hamstring tendons are equally good graft material as the patellar tendon in ACL reconstruction. Ninety-nine patients with laxity due to a torn ACL underwent arthroscopically assisted reconstruction with graft randomization according to their birth year to either patellar tendon with metal interference screw fixation or double looped semitendinosus and gracilis tendons with fixation similar to the Endobutton technique using a titanium metal plate suspension proximally and screw-washer postdistally. Excluding preoperative Lysholm knee score, there were no significant differences between the two groups in the preoperative and operative data. A standard rehabilitation regimen was used for all the patients, including immediate postoperative mobilization without a knee brace, protected weight bearing for 2 weeks, and return to full activity at 6–12 months postoperatively. Forty patients in the patellar tendon group and 39 patients in the hamstring tendon group were available for clinical evaluation at median 5 years after surgery (ranges 3 years 11 months–6 years 7 months). The results revealed no statistically significant differences with respect to clinical and instrumented laxity testing, isokinetic muscle torque measurements, International Knee Documentation Committee ratings, Lysholm (knee score), Tegner (activity level) and Kujala patellofemoral knee scores. There was an enlargement of the drill tunnels, statistically more in the hamstring tendon group, but no increase from 2 to 5 years in either group. Narrowing of the joint spaces (IKDC measurement method) from 2 to 5 years postoperatively was seen in both the groups, however, without difference between the two groups.     

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     

Anterior cruciate ligament patellar tendon reconstruction: it is probably better to leave the tendon defect open!

The purpose of our prospective study was to establish whether or not in anterior cruciate ligament (ACL) patellar tendon reconstruction the tendon defect has to be closed. In 50 consecutive ACL patellar tendon reconstructions, the tendon defect was randomly closed (group I) or left open (group II). The following data were recorded from all patients on the 4th and 14th days post operation: range of motion (ROM), pain at rest, pain and validity at isometric contraction, ability of bent leg raising (at 4th day) and straight leg raising (at 14th day). All the patients underwent ultrasonographic examination after 3 months and X-ray scanning at 6 months post operation. Forty patients underwent a CT-scan examination at 6 months. Thirty patients underwent isokinetic testing between 10 and 12 months post operation. Evaluating the immediate post operation data, no statistically significant differences emerged between the two groups. Ultrasonography showed in 68% of the knees of group I (defect closed) a thickened patellar tendon (PT), while in 60% of group II it was of normal thickness. No patients of either group developed patella infera by X-ray evaluation 6 months post operation. CT scans at 6 months showed that 100% of the knees of group I had a thickened PT in toto (nearly twice as thick as normal). Scar tissue was present not only in its central third but also in more than half of the cases in the medial and lateral third. In group II 75% of the patients had a normal thickness PT and 25% presented with only a minimal thickening. Scar tissue was distinguished only at its central third. Some 32% and 36% of the patients of group I and II, respectively, developed patellar irritability between the 5th and 8th month post operation. Isokinetic tests performed between the 10th and 12th months showed that the quadriceps deficit was slightly less in group II than in group I. Our study did not show very important clinical differences between the two groups but revealed that if the tendon defect is closed, an exuberant scar process arises involving the entire PT. This could mean, as reported in the literature, a high reduction in the biomechanical properties of the PT. For this reason it is probably better to leave the defect open.     

关节镜下自体半腱及股薄肌腱重建膝前交叉韧带

 目的 探讨关节镜下以自体半腱肌、股薄肌腱重建膝前交叉韧带(ACL)的手术方法及疗效.方法 自2006年3月～2007年12月,关节镜下绳肌腱修复膝前交叉韧带损伤39例.膝前小切口取半腱肌腱、股薄肌腱修整、对折后成四股,分别建立胫骨隧道及股骨隧道,用Endobutton和生物可吸收挤压螺钉固定肌腱,重建ACL的解剖结构和生理功能.术后即行功能锻练.结果 术后患者伤口均Ⅰ期愈合,8～10周膝关节屈伸功能恢复正常.随访时间3～15个月,平均8个月.抽屉试验和Lachman试验阳性者2例,可疑阳性者6例;余患者均为阴性.根据敖英芳临床判断标准,本组优23例,良11例,中3例,差2例.Lysholm评分术后(87.6±4.6),与术前(45.3±4.2)比较,差异显著(P<0.01).结论 绳肌腱具有良好的抗拉强度和刚度,在关节镜下用四股绳肌腱重建膝前交叉韧带是一种疗效可靠的治疗方式.     

Initial fixation strength of interference nail fixation for anterior cruciate ligament reconstruction with patellar tendon graft (experimental study)

The objective of this study was to evaluate initial fixation strength of a new interference nail fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft. Human cadaver knees were used. Fixation strengths ranged from 500 N to 600 N (mean 550 N). This corresponds to loads in the graft during aggressive rehabilitation. No slippage occurred at fixation site of specimens. Most of the failures appeared from the femoral side with tendon ruptures. With respect to primary fixation strength, interference nail fixation is a reasonable alternative for anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.     

Tibial tunnel area changes following arthroscopic anterior cruciate ligament reconstructions with autogenous patellar tendon graft

We investigated radiographic changes in tibial tunnel area after ACL reconstructions with autogenous patellar tendon grafts on anteroposterior and lateral radiographs over 3 years. Fifty patients followed up for at least 1 year were included in the study. Radiographs were taken on the day of surgery and 3, 6, 9, 12, 24, and 36 months postoperatively. Tibial tunnels on both radiographs were divided into proximal, middle, and distal one-third. The area of each one-third and the greatest diameter of the tibial tunnel on both radiographs was measured using an image-processing software. According to the tunnel area changes, the shape of tibial tunnel was classified into one of four shapes; cylinder, mallet, reverse bottle, and reverse triangle. The correlations between area, diameter and shape of the tunnel, and clinical variables including arthrometer measurement and clinical score were determined. The areas of each one-third of the tibial tunnels on lateral radiographs was always greater than that on anteroposterior radiographs, although the diameters on the two radiographs did not differ significantly. The area of proximal one-third largest and that of distal one-third smallest on both radiographs at any time point. The enlargement and reduction occurred within 3 months and tended to continue for 9 months. Thereafter the tunnel change stabilized on both radiographs. The most common shape of the enlarged tunnels was cylindrical on anteroposterior radiographs reverse triangle on lateral radiographs. No negative effects of enlarged area, diameter, or tunnel shape on clinical results were found in our study.     

Comparison of femoral fixation methods for anterior cruciate ligament reconstruction with patellar tendon graft: a mechanical analysis in porcine knees

The aim of the present study was to evaluate the structural properties of femur–patellar tendon graft complex in anterior cruciate ligament (ACL) reconstruction using different femoral fixation devices. Type of study is biomechanical testing. An ACL reconstruction was performed on 40 cadaver porcine knees, using patellar tendon (PT) graft. Specimens were divided into four groups according to the femoral fixation: interference absorbable screw (Group A), metallic setscrew (Group B), absorbable pins (Group C), and a combination of metallic setscrew and pin (Group D). Other ten knees were used as controls. On each sample, a cyclic loading test, then a load-to-failure test were performed. Elongation after 1,000 loading cycles, ultimate failure load, yield load, stiffness, deformation at the yield point, and mode of failure were recorded. Kruskal–Wallis test and Tukey test were used to compare the differences between groups. The lowest mean elongation after 1,000 load cycles was observed for Group B (1.7 ± 1.4 mm) and D (1.2 ± 0.3 mm). Ultimate failure load of Group D (1,021.8 ± 199.4 N) was comparable with that of normal ACL (1,091.2 ± 193.3 N) and PT graft (1,140.6 ± 285.7 N). All other groups were lower than the controls. For mean stiffness, all the groups, excepting for Group D (172.8 ± 40.4 N/mm), were significantly lower than PT control group (216 ± 78.4 N/mm). Mode of failure was graft pullout for Groups A and B, distal pin breakage for Group C, and midsubstance graft rupture in 80% of the cases for Group D. Only combined compression and suspension fixation did not show significantly different structural properties in comparison with normal ACL and PT graft. Furthermore, it showed no risk of graft pullout or hardware breakdown in comparison with other fixation devices.     

No benefit of bracing on the early outcome after anterior cruciate ligament reconstruction

Forty patients were prospectively investigated to evaluate the effects of bandaging after reconstructive surgery of the anterior cruciate ligament (ACL). For the 6 weeks of the postoperative course, the operated knee was bandaged in 20 patients (group A) and braced in the other 20 patients (group B). The isokinetic torque for extension and flexion (Cybex) and the range of motion (ROM) were investigated after 6, 12, 24 and 52 weeks postoperatively. At 24 weeks and 1 year postoperatively the stability of the knee joint (KT-1000) as well as the clinical outcome (‘Orthopädische Arbeitsgemeinschaft Knie’) were evaluated. No statistically significant differences between the two groups were found for the extension and flexion strengths. Free ROM was achieved significantly earlier in group A than in group B. No statistically significant differences regarding the stability of the operated knee joint nor the early outcome were found between the two groups. This study demonstrated that the renunciation of using a brace had no adverse effect on the early outcome with respect to stability and function. On the contrary, bracing seems not to be mandatory after ACL reconstruction when the central third of the patellar tendon is used.     

Dynamic joint loading following hamstring and patellar tendon anterior cruciate ligament reconstruction

This study compared lower limb dynamic joint loading after hamstring (HS) and patellar tendon (PT) anterior cruciate ligament (ACL) reconstruction. A three-dimensional motion analysis and force plate system were used to determine sagittal plane kinematics and kinetics in 20 subjects who had undergone ACL reconstruction (10 HS, 10 PT) whilst they performed both horizontal and vertical hopping tasks. Results for both activities showed significantly smaller knee flexion angles and external flexion moments in the operated than the non-operated limbs in PT subjects but no difference between limbs in HS subjects. There was no difference in the summated moment (hip plus knee plus ankle) between limbs for either graft type. The peak vertical ground reaction force was greater in the operated than the non-operated limb in PT subjects during the horizontal hop. These data show functional knee kinematic and kinetic differences between the two graft types that point to an earlier or better functional recovery in patients undergoing ACL reconstruction with HS graft than PT graft.     

One-stage bilateral anterior cruciate ligament reconstruction with use of hamstring tendon autografts: a case report

This article presents an unusual problem of a patient with chronic bilateral ACL-deficient knees and constitutionally very thin patellar tendons. Author decided to perform one-stage bilateral ACL reconstructions using hamstring tendon autografts so as not to weaken his quadriceps muscles by compromising his extensor mechanism.     

MRI of anterior cruciate ligament repair with patellar and hamstring tendon autografts

Objective. Several MRI sequences were used to evaluate the 2-year postoperative appearance of asymptomatic knee with a torn anterior cruciate ligament (ACL) reconstructed with bone–patellar tendon–bone (BTB) and semitendinosus and gracilis (STG) tendon autografts. Design and patients. Two groups with successful repair of ACL tear with BTB (n=10) or STG (n=10) autografts were imaged at 1.5 T with sagittal and oblique coronal proton density-, T2-weighted and sagittal STIR sequences and plain and contrast-enhanced oblique coronal T1-weighted sequences. The appearance of the graft and periligamentous tissues was evaluated. Results. In all 20 cases, the ACL graft showed homogeneous, low signal intensity with periligamentous streaks of intermediate signal intensity on T2-weighted images. In 10 cases, localised areas of intermediate signal intensity were seen in the intra-articular segment of the graft on proton density- and T1-weighted images. The graft itself did not show enhancement in either of the two groups, but mild to moderate periligamentous enhancement was detected in 10 cases. Conclusion. The MRI appearance of ACL autograft is variable on proton density- and T1-weighted images. Periligamentous tissue showing contrast enhancement is a typical MRI finding after clinically successful ACL reconstruction. Received: 22 February 2000 Revision requested: 27 June 2000 Revision received: 21 August 2000 Accepted: 23 August 2000