Eric Linko

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.

BACKGROUND: Anterior cruciate ligament rupture is a common knee injury. Surgical treatment, usually involving reconstruction of the ligament, is widely used especially in active individuals. OBJECTIVES: Evaluation of the effect of surgical treatment compared with conservative treatment of anterior cruciate ligament (ACL) rupture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to January Week 3 2005), EMBASE (1988 to 2005 Week 05), MEDIC (1978 to January 1999), Current Contents (9.2.1998 to 1.2.1999), BIOSIS (1970 to December 1998), reference lists of articles and consulted trialists and experts. SELECTION CRITERIA: All randomised and quasi-randomised trials that compared surgical with conservative treatment of ACL rupture in adults. DATA COLLECTION AND ANALYSIS: Two authors independently performed study selection, data extraction and quality assessment. MAIN RESULTS: Two poor quality randomised trials conducted in the early 1980s were included in the review. The two trials differed considerably and no data pooling was done for the few shared outcome measures. One quasi-randomised trial of 167 people with a complete ACL rupture treated with repair or augmented repair versus conservative treatment found no difference in the return to sports activities between people treated surgically and those treated conservatively. Measures of knee stability and functional (Lysholm) knee scores were higher in surgically-treated participants. By the end of the follow-up period (average 55 months), three people treated with repair only and 16 treated conservatively had had ACL reconstruction. The other trial included 157 people with ACL injury. This found that conservatively-treated participants recovered from their injury more rapidly but, at the last follow up (minimum 13 months), the functional outcome was similar in both treatment groups. A large proportion of participants experienced some temporary discomfort after surgery and there were some more serious postoperative complications. There was less knee instability in surgically-treated participants and a tendency to fewer subsequent operations in the longer term. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice. Good quality randomised trials are required to remedy this situation.

This review has been withdrawn, as of Issue 4, 2016, because it has been superseded by a new review (Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011166. DOI:10.1002/14651858.CD011166.pub2).

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.

We prospectively compared the outcome of anterior cruciate ligament reconstruction using patellar tendon autograft with outcome using hamstring tendon autograft. Ninety-nine patients with laxity due to a torn anterior cruciate ligament underwent arthroscopically assisted reconstruction with graft randomization according to birth year. Excluding preoperative Lysholm score there were no significant differences between the 2 groups in preoperative and operative data. A standard rehabilitation regimen was used for all patients including immediate mobilization without a knee brace, protected weight bearing for 2 weeks, and return to full activity at 6 to 12 months postoperatively.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 (range 21 to 38 months). The results revealed no statistically significant differences with respect to clinical and instrumented laxity testing, International Knee Documentation Committee ratings, isokinetic muscle torque measurements, Lysholm (knee score), Tegner (activity level) and Kujala patellofemoral knee score. The patellar and hamstring tendon autograft anterior cruciate ligament reconstructions showed equal results 2 years after surgery. Both techniques seem to improve patients’ performance. We prospectively compared the outcome of anterior cruciate ligament reconstruction using patellar tendon autograft with outcome using hamstring tendon autograft. Ninety-nine patients with laxity due to a torn anterior cruciate ligament underwent arthroscopically assisted reconstruction with graft randomization according to birth year. Excluding preoperative Lysholm score there were no significant differences between the 2 groups in preoperative and operative data. A standard rehabilitation regimen was used for all patients including immediate mobilization without a knee brace, protected weight bearing for 2 weeks, and return to full activity at 6 to 12 months postoperatively. 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 (range 21 to 38 months). The results revealed no statistically significant differences with respect to clinical and instrumented laxity testing, International Knee Documentation Committee ratings, isokinetic muscle torque measurements, Lysholm (knee score), Tegner (activity level) and Kujala patellofemoral knee score. The patellar and hamstring tendon autograft anterior cruciate ligament reconstructions showed equal results 2 years after surgery. Both techniques seem to improve patients’ performance.