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Autologous patellar tendon and quadrupled hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized multicenter review of different fixation methods

  • Knee
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

ACL reconstruction with bone patellar tendon bone (BPTB) grafts has been shown to produce dependable results. Recently, reconstructions with double-looped semitendinosus gracilis (DLSG) grafts have become common. The prevailing opinion is that ACL reconstruction with patellar tendon graft produces a more stable knee with more anterior knee pain than DLSG grafts, while the functional results and knee scores are similar. The present study evaluates BPTB grafts fixed with metallic interference screws and DLSG grafts fixed with Bone Mulch Screw on the femur and WasherLoc fixation on the tibia. All else being the same, there is no difference in the outcome between the two grafts and fixation methods. This is a prospective randomized multicenter study. A total of 115 patients with isolated ACL ruptures were randomized to either reconstruction with BPTB grafts fixed with metal interference screws (58 patients) or DLSG grafts (57 patients) fixed with Bone Mulch Screws and WasherLoc Screws. Follow-up was at one and two years; the latter by an independent observer. At two years, one ACL revision had been performed in each group. Eight patients in the DLSG group and one in the BPTB group underwent meniscus surgery in the follow-up period (P = 0.014). Mean Lysholm score at the two year follow-up was 91 (SD ± 10.3) in the DLSG group and also 91 (SD ± 10.2) in the BPTB group. Mean KT-1000 at two years was 1.5 mm in the BPTB group and 1.8 mm in the DLSG group (n.s.). At two years, four patients in the BPTB group and three in the DLSG group had a Lachman test grade 2 or 3 (n.s.). More patients in the BPTB group had pain at the lower pole of the patella (P = 0.04). Peak flexion torque and total flexion work were lower in the DLSG group at one year (P = 0.003 and P = 0.000) and total flexion work also at two years (P = 0.05). BPTB ACL reconstruction fixed with interference screws and DLSG fixed with Bone Mulch Screws on the femur and WasherLoc Screws on the tibia produce satisfactory and nearly identical outcomes. Among our patients in the DLSG group, flexion strength was lower, and more patients underwent meniscus surgery in the follow-up period. The BPTB group has more anterior knee pain.

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References

  1. Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F (2004) Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective randomized clinical trial. J Bone Joint Surg Am 86:2143–2155

    PubMed  Google Scholar 

  2. Aglietti P (1994) A comparison between medial meniscus repair, partial meniscectomy, and normal meniscus in anterior cruciate ligament reconstructed knees. Clin Orthop Relat Res 307:165–173

    PubMed  Google Scholar 

  3. Aglietti P (1994) Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med 22:211–217

    Article  CAS  PubMed  Google Scholar 

  4. Anderson AF, Dome DC, Gautam S, Awh MH, Rennirt GW (2001) Correlation of anthropometric measurements, strength, anterior cruciate ligament size, and intercondylar notch characteristics to sex differences in anterior cruciate ligament tear rates. Am J Sports Med 29:58–66

    CAS  PubMed  Google Scholar 

  5. Arnold JA, Coker TP, Heaton LM, Park JP, Harris WD (1979) Natural history of anterior cruciate tears. Am J Sports Med 7:305–313

    Article  CAS  PubMed  Google Scholar 

  6. Aune AK, Holm I, Risberg MA, Jensen HK, Steen H (2001) Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med 29:722–728

    CAS  PubMed  Google Scholar 

  7. Barber FA (2000) Bioscrew fixation of patellar tendon autografts. Biomaterials 21:2623–2629

    Article  CAS  PubMed  Google Scholar 

  8. Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renstrom P (2002) Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 84:1503–1513

    PubMed  Google Scholar 

  9. Bray RC, Dandy DJ (1989) Meniscal lesions and chronic anterior cruciate ligament deficiency. Meniscal tears occurring before and after reconstruction. J Bone Joint Surg Br 71:128–130

    CAS  PubMed  Google Scholar 

  10. Buss DD, Min R, Skyhar M, Galinat B, Warren RF, Wickiewicz TL (1995) Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients. Am J Sports Med 23:160–165

    Article  CAS  PubMed  Google Scholar 

  11. Corry IS (1999) Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 27:444–454

    CAS  PubMed  Google Scholar 

  12. Drogset JO, Grontvedt T (2002) Anterior cruciate ligament reconstruction with and without a ligament augmentation device : results at 8-Year follow-up. Am J Sports Med 30:851–856

    PubMed  Google Scholar 

  13. Drogset JO, Grontvedt T, Tegnander A (2005) Endoscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone grafts fixed with bioabsorbable or metal interference screws: a prospective randomized study of the clinical outcome. Am J Sports Med 33:1160–1165

    Article  PubMed  Google Scholar 

  14. Drogset JO, Grontvedt T, Robak OR, Molster A, Viset AT, Engebretsen L (2006) A sixteen-year follow-up of three operative techniques for the treatment of acute ruptures of the anterior cruciate ligament. J Bone Joint Surg Am 88:944–952

    Article  PubMed  Google Scholar 

  15. Eastlack ME, Axe MJ, Snyder-Mackler L (1999) Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc 31:210–215

    Article  CAS  PubMed  Google Scholar 

  16. Ejerhed L, Kartus J, Sernert N, Kohler K, Karlsson J (1999) Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up. Am J Sports Med 7:19–25

    Google Scholar 

  17. Ejerhed L, Kartus J, Kohler K, Sernert N, Brandsson S, Karlsson J (2003) Preconditioning patellar tendon autografts in arthroscopic anterior cruciate ligament reconstruction: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 52:6–11

    Google Scholar 

  18. Eriksson K, Anderberg P, Hamberg P, Lofgren AC, Bredenberg M, Westman I, Wredmark T (2001) A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 83:348–354

    Article  CAS  PubMed  Google Scholar 

  19. Fauno P, Kaalund S (2005) Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: a prospective randomized study. Arthroscopy 21:1337–1341

    Article  PubMed  Google Scholar 

  20. Feagin JA Jr, Curl WW (1976) Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med 4:95–100

    Article  PubMed  Google Scholar 

  21. Feller JA, Webster K (2003) A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med 31:564–573

    PubMed  Google Scholar 

  22. Fitzgerald GK, Axe MJ, Snyder-Mackler L (2000) A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 8:76–82

    Article  CAS  PubMed  Google Scholar 

  23. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr (2003) Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 31:2–11

    PubMed  Google Scholar 

  24. Gobbi A, Mahajan S, Zanazzo M, Tuy B (2003) Patellar tendon versus quadrupled bone-semitendinosus anterior cruciate ligament reconstruction: a prospective clinical investigation in athletes. Arthroscopy 19:592–601

    Article  PubMed  Google Scholar 

  25. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC (2005) Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 21:791–803

    Article  PubMed  Google Scholar 

  26. Granan L, Bahr R, Steindal K, Furnes O, Engebretsen L (2008) Development of a national cruciate ligament surgery registry: the norwegian national knee ligament registry. Am J Sports Med 36:308–315

    Article  PubMed  Google Scholar 

  27. Grontvedt T, Engebretsen L, Bredland T (1996) Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone grafts with and without augmentation. A prospective randomised study. J Bone Joint Surg Br 78:817–822

    CAS  PubMed  Google Scholar 

  28. Harilainen A, Linko E, Sandelin J (2006) 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. Knee Surg Sports Traumatol Arthrosc 14:517–528

    Article  PubMed  Google Scholar 

  29. Hawkins RJ, Misamore GW, Merritt TR (1986) Followup of the acute nonoperated isolated anterior cruciate ligament tear. Am J Sports Med 14:205–210

    Article  CAS  PubMed  Google Scholar 

  30. Jacobsen K (1977) Osteoarthrosis following insufficiency of the cruciate ligaments in man. A clinical study. Acta Orthop Scand 48:520–526

    Article  CAS  PubMed  Google Scholar 

  31. Jarvela T, Moisala AS, Sihvonen R, Jarvela S, Kannus P, Jarvinen M (2008) Double-bundle anterior cruciate ligament reconstruction using hamstring autografts and bioabsorbable interference screw fixation: prospective, randomized, clinical study with 2-year results. Am J Sports Med 36:290–297

    Article  PubMed  Google Scholar 

  32. John PG, Sean EF, Ethan B, John CR (2005) Reconstruction of the anterior cruciate ligament: meta-analysis of Patellar tendon versus Hamstring tendon autograft. Arthroscopy 21:791–803

    Article  Google Scholar 

  33. Kartus J, Stener S, Lindahl S, Engstrom B, Eriksson B, Karlsson J (1997) Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts. Knee Surg Sports Traumatol Arthrosc 5:222–228

    Article  CAS  PubMed  Google Scholar 

  34. Kartus J, Movin T, Karlsson J (2001) Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy 17:971–980

    Article  CAS  PubMed  Google Scholar 

  35. Kraemer WJ, Adams K, Cafarelli E, Dudley GA, Dooly C, Feigenbaum MS, Fleck SJ, Franklin B, Fry AC, Hoffman JR, Newton RU, Potteiger J, Stone MH, Ratamess NA, Triplett-McBride T (2002) American college of sports medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc 34:364–380

    Article  PubMed  Google Scholar 

  36. Lawhorn KW, Howell SM (2003) Scientific justification and technique for anterior cruciate ligament reconstruction using autogenous and allogeneic soft-tissue grafts. Orthop Clin North Am 34:19–30

    Article  PubMed  Google Scholar 

  37. Lee Y, Kim SK, Park JH, Park JW, Wang JH, Jung YB, Ahn JH (2007) Double-bundle anterior cruciate ligament reconstruction using two different suspensory femoral fixation: a technical note. Knee Surg Sports Traumatol Arthrosc 15:1023–1027

    Article  PubMed  Google Scholar 

  38. Liden M, Ejerhed L, Sernert N, Laxdal G, Kartus J (2007) Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-Year follow-up. Am J Sports Med 35:740–748

    Article  PubMed  Google Scholar 

  39. Lind M, Menhert F, Pedersen AB (2009) The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5, 818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 17:117–124

    Article  PubMed  Google Scholar 

  40. Maletis GB, Cameron SL, Tengan JJ, Burchette RJ (2007) A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. Am J Sports Med 35:384–394

    Article  PubMed  Google Scholar 

  41. Marder RA, Raskind JR, Carroll M (1991) Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med 19:478–484

    Article  CAS  PubMed  Google Scholar 

  42. Marder RA, Raskind JR, Carroll M (1996) Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med 20:478–484

    Google Scholar 

  43. Matsumoto A, Yoshiya S, Muratsu H, Yagi M, Iwasaki Y, Kurosaka M, Kuroda R (2006) A comparison of bone-patellar tendon-bone and bone-hamstring tendon-bone autografts for anterior cruciate ligament reconstruction. Am J Sports Med 34:213–219

    Article  PubMed  Google Scholar 

  44. McDaniel WJ Jr, Dameron TB Jr (1983) The untreated anterior cruciate ligament rupture. Clin Orthop Relat Res 172:158–163

    PubMed  Google Scholar 

  45. Neeter C, Gustavsson A, Thomee P, Augustsson J, Thomee R, Karlsson J (2006) Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surg Sports Traumatol Arthrosc 14:571–580

    Article  PubMed  Google Scholar 

  46. Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am 65:154–162

    CAS  PubMed  Google Scholar 

  47. Noyes F, Barber SD, Mangine RE (1991) Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med 19:513–518

    Article  CAS  PubMed  Google Scholar 

  48. Ostenberg A, Roos E, Ekdahl C, Roos H (1998) Isokinetic knee extensor strength and functional performance in healthy female soccer players. Scand J Med Sci Sports 8:257–264

    CAS  PubMed  Google Scholar 

  49. Pinczewski LA, Deehan DJ, Salmon LJ, Russell VJ, Clingeleffer A (2002) A five-year comparison of patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the anterior cruciate ligament. Am J Sports Med 30:523–536

    PubMed  Google Scholar 

  50. Poolman RW, Farrokhyar F, Bhandari M (2007) 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. Acta Orthopaedica 78:350–354

    Article  PubMed  Google Scholar 

  51. Prodromos CC, Fu FH, Howell SM, Johnson DH, Lawhorn K (2008) Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation, and harvest. J Am Acad Orthop Surg 16:376–384

    PubMed  Google Scholar 

  52. Risberg MA, Ekeland A (1994) Assessment of functional tests after anterior cruciate ligament surgery. J Orthop Sports Phys Ther 19:212–217

    CAS  PubMed  Google Scholar 

  53. Sajovic M, Vengust V, Komadina R, Tavcar R, Skaza K (2006) A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up. Am J Sports Med 34:1933–1940

    Article  PubMed  Google Scholar 

  54. Shelbourne KD, Gray T (1997) Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med 25:786–795

    Article  CAS  PubMed  Google Scholar 

  55. Shelbourne KD, Urch SE (2000) Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med 28:651–658

    CAS  PubMed  Google Scholar 

  56. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo MS (1995) Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program. Am J Sports Med 23:575–579

    Article  CAS  PubMed  Google Scholar 

  57. Steiner ME, Hecker AT, Brown CH Jr, Hayes WC (1994) Anterior cruciate ligament graft fixation. Comparison of hamstring and patellar tendon grafts. Am J Sports Med 22:240–246

    Article  CAS  PubMed  Google Scholar 

  58. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop 198:43–49

    PubMed  Google Scholar 

  59. Wagner M, Kaab MJ, Schallock J, Haas NP, Weiler A (2005) Hamstring tendon versus patellar tendon anterior cruciate ligament reconstruction using biodegradable interference fit fixation: a prospective matched-group analysis. Am J Sports Med 33:1327–1336

    Article  PubMed  Google Scholar 

  60. Zantop T, Kubo S, Petersen W, Musahl V, Fu FH (2007) Current techniques in anatomic anterior cruciate ligament reconstruction. Arthroscopy 23:938–947

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Professor Lars Engebretsen for the assistance with the manuscript and Physiotherapist Øystein Skare for the independent observations.

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Authors and Affiliations

  1. Department of Orthopaedics, St. Olav’s Hospital, 7006, Trondheim, Norway

    Jon Olav Drogset

  2. Department of Orthopaedics, Bergen Deaconal Hospital, Bergen, Norway

    Torbjørn Strand

  3. Department of Orthopaedics, Lovisenberg Diakonale Hospital, Oslo, Norway

    Gisle Uppheim & Bjørn Ødegård

  4. Bergen Spine Centre, Bergen, Norway

    Asbjørn Bøe

  5. Rosenborg Clinic, Trondheim, Norway

    Torbjørn Grøntvedt

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  1. Jon Olav Drogset
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  2. Torbjørn Strand
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Correspondence to Jon Olav Drogset.

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Drogset, J.O., Strand, T., Uppheim, G. et al. Autologous patellar tendon and quadrupled hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized multicenter review of different fixation methods. Knee Surg Sports Traumatol Arthrosc 18, 1085–1093 (2010). https://doi.org/10.1007/s00167-009-0996-5

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