Bone-patellar Tendon-bone Group Research Articles

Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions

Several studies compare the short- and long-term results of anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft or double-looped semitendinosus and gracilis (DLSG) graft. However, no studies evaluate the long-term results of BPTB grafts fixed with metal interference screws and DLSG grafts fixed with the Bone Mulch Screw and the Washer Loc. This prospective randomized multicentre study has the null hypothesis that there is no difference in long-term outcome between the two procedures. A total of 114 patients with a symptomatic ACL rupture were randomized to reconstruction with either a BPTB graft (N=58) or a DLSG graft (N=56). Follow-up was conducted after one, two and sevenyears. At the seven-year follow-up, 102 of the 114 patients (89%) were available for evaluation; however, 16 of these by telephone-interview only. Ten patients in the BPTB group and 19 patients in the DLSG group underwent additional knee surgery (P=0.048), two and three, respectively, of these were ACL revisions (n.s.). The total flexion work was lower in the DLSG group (P=0.001). The mean peak flexion torque and extension work, however, showed no difference between the groups. No significant differences were found between the groups regarding the Tegner activity score, the Lysholm functional score, the Knee injury and osteoarthritis outcome score (KOOS), subjective knee function, anterior knee pain or mobility. There was no significant difference in laxity between the groups on the Lachman test or the KT-1,000 maximum manual force test. Both grafts and fixation methods resulted in satisfactory subjective outcome and objective stability. Both these methods can therefore be considered as suitable alternatives for ACL reconstructions. II.

Whatʼs New in Sports Medicine

It is once again an honor and a privilege to be asked to present this update for the subspecialty of sports medicine. Sports medicine continues to be an expanding subspecialty field that crosses many boundaries. As mentioned in previous updates, however, our central mission remains the same—the care of the athlete. This update is based on scientific and organizational activities in sports medicine that took place from September 2003 to August 2004. It includes a summary of the Annual and Specialty Day Meetings of the American Orthopaedic Society for Sports Medicine (AOSSM), the Arthroscopy Association of North America (AANA), and the American Academy of Orthopaedic Surgeons (AAOS). These meetings featured more than 200 scientific presentations, including both clinical and basic-science studies, that focused primarily on sports medicine. The three most influential journals in our field will be reviewed again this year, specifically, The Journal of Bone and Joint Surgery, The American Journal of Sports Medicine, and Arthroscopy. ### Anterior Cruciate Ligament The optimum graft choice for anterior cruciate ligament reconstruction remains controversial. Several recent randomized, controlled studies showed equivalent results in association with both bone-patellar tendon-bone and quadrupled hamstring grafts, effectively endorsing a “double gold standard.” An additional randomized, prospective trial from Australia showed satisfactory functional outcomes in association with both types of grafts after three years of follow-up1. As in other studies, however, the authors noted increased kneeling pain in the bone-patellar tendon-bone group and slightly increased laxity and femoral tunnel widening in the hamstring group. Recent histological studies have shown that neither type of graft regenerates to a normal functional tendon. In two independent studies involving the use of magnetic resonance imaging and ultrasound examination following bone-patellar tendon-bone graft harvest, the patellar tendon had not normalized by six to ten years postoperatively2,3. Both groups of authors …

CSM 2010 Sports Physical Therapy Section Platform Presentations (Abstracts SPL1-SPL27)

CSM 2010 Sports Physical Therapy Section Platform Presentations (Abstracts SPL1-SPL27)

Comparison of Clinical Results and Second-Look Arthroscopy Findings After Arthroscopic Anterior Cruciate Ligament Reconstruction Using 3 Different Types of Grafts

The purpose of this study was to compare the outcomes after anterior cruciate ligament reconstructive surgery by use of bone-patellar tendon-bone (BPTB) allografts, tibialis anterior tendon (TA) allografts, and hamstring tendon (HA) autografts with respect to objective knee testing measures and second-look arthroscopy. We analyzed 338 patients who had undergone anterior cruciate ligament reconstruction between March 2000 and February 2006. BPTB allografts were used in 60 cases, TA allografts in 153 cases, and HA autografts in 125 cases. We compared the grade of range of motion (ROM), Lachman test, pivot-shift test, KT-1000 arthrometric test (MEDmetric, San Diego, CA), and International Knee Documentation Committee (IKDC) knee examination form, as well as second-look arthroscopic findings, at least 1 year after reconstruction. The preoperative ROM was not different among the 3 groups (P > .05), but the BPTB group and TA group showed greater postoperative ROM than the HA group (P = .028 and P < .001, respectively). There was no difference among the 3 groups in the other objective testing measurements (P > .05). Synovial coverage of more than 50% was found in 62.5% cases in the BPTB allograft group, 72.3% cases in the TA allograft group, and 90.7% cases in the HA autograft group. The incidence of synovial coverage of more than 50% was higher in the HA autograft group than that in the BPTB and TA allograft groups (P = .018 and P = .026, respectively). With regard to the IKDC grade, grade A or B was found in 95.2% of the cases with synovial coverage of more than 50% and in 78.3% of the cases with coverage of less than 50% (P = .011). There was no difference in objective knee testing measures among the 3 different graft groups except that the allograft groups showed greater postoperative ROM than the autograft group. However, the HA autograft group had better synovial coverage on second-look arthroscopy, and the group with better synovial coverage on second-look arthroscopy presented better clinical results on the IKDC objective examination form.

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

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.

Knee laxity measurements after anterior cruciate ligament reconstruction, using either bone–patellar–tendon–bone or hamstring tendon autografts, with special emphasis on comparison over time

The aims of the study were to analyse the change in knee laxity over time after anterior cruciate ligament (ACL) reconstruction, using either bone-patellar-tendon-bone (BPTB) or hamstring (HS) tendon autografts, and to compare the knee laxity measurements between the study groups both pre-operatively and on multiple follow-up occasions. Another aim was to compare the radiographic findings in terms of degenerative changes between the study groups. A randomised series of 71 patients, who underwent ACL reconstruction using BPTB or HS tendon autografts and interference screw fixation, were included in the study. Of these patients, 47/71 (66%) attended a clinical examination, including laxity measurements using the KT-1000 arthrometer, pre-operatively and on four post-operative occasions; 6 months, 1 year, 2 years and 7 years after the reconstruction. The BPTB group consisted of 22 patients, while there were 25 patients in the HS group. There were no significant differences in the mean side-to-side knee laxity between the BPTB and the HS group pre-operatively or at the follow-up examinations. There was a tendency towards a reduction in side-to-side knee laxity over time in both groups, measured with the KT-1000 arthrometer. The decrease was significant when analysing the injured and uninjured knee separately (injured side p < 0.001 (BPTB) and p = 0.005 (HS), uninjured side p = 0.008 and p = 0.042, respectively). Forty-four patients (BPTB 21, ST 23) underwent a radiographic assessment at the 7-year follow-up, which revealed no significant differences between the study groups in terms of osteoarthritic findings classified according to the Fairbank and Ahlbäck rating systems. In overall terms, osteoarthritis was identified in 16% (BPTB 19%; ST 13%; n.s.) according to the Ahlbäck rating system and 68% (BPTB 67%; ST 70%; n.s.) according to the Fairbank rating system. There were no significant differences in knee laxity measurements between the two study groups pre-operatively or at 7 years. A decrease in knee laxity over time was seen in both groups. There were no significant differences between the BPTB and ST groups in terms of osteoarthritic findings at 7 years.

Whatʼs New in Sports Medicine

1Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22908-0159. E-mail address for M.D. Miller: [email protected]

Anterior Cruciate Ligament Reconstruction: Autogenous Quadriceps Tendon–Bone Compared With Bone–Patellar Tendon–Bone Grafts at 2-Year Follow-up

The purpose of this study was to evaluate and compare postoperative anterior knee pain, knee stability, and functional scores of an autogenous bone-patellar tendon-bone (BPTB) graft and a quadriceps tendon-bone (QTB) graft. A total of 48 patients--27 who had anterior cruciate ligament (ACL) reconstruction by use of an autogenous BPTB graft and 21 who had ACL reconstruction by use of a QTB graft--were assessed at a minimum follow-up of 24 months after surgery. An accelerated rehabilitation program was adapted, and the rehabilitation protocol was identical for both groups. The mean side-to-side difference as measured with a KT-2000 arthrometer (MEDmetric, San Diego, CA) was 2.73 mm (SD, 1.45 mm) in the BPTB group and 2.79 mm (SD, 1.32 mm) in the QTB group (P = .880). Postoperatively, the International Knee Documentation Committee score was grade A or B in 23 patients (85.2%) in the BPTB group and 18 (85.7%) in the QTB group (P = .997). The mean anterior knee pain score was 86.9 in the BPTB group as compared with 90.2 in the QTB group (P = .107). In a kneeling posture, 13 BPTB patients reported discomfort (moderate in 10 and severe in 3) whereas only 4 QTB patients had moderate discomfort (P = .029). No significant differences were found with regard to other activities surveyed. A QTB graft attached with the EndoPearl device (Linvatec, Largo, FL) appears to be an effective alternative for single-bundle ACL reconstruction. When followed with an accelerated rehabilitation program, reconstruction with a QTB graft provided knee stability comparable to a BPTB graft but with less kneeling pain than a BPTB graft.

Autograft Contamination During Preparation for Anterior Cruciate Ligament Reconstruction

The autograft preparation process for anterior cruciate ligament reconstruction has a potential for graft contamination. The purpose of this study was to evaluate the possibility of contamination of the bone-patellar tendon-bone and hamstring tendon autograft during preparation for anterior cruciate ligament reconstruction. A primary isolated reconstruction of the anterior cruciate ligament with use of bone-patellar tendon-bone autograft (thirty patients) and hamstring tendon autograft (thirty patients) was performed in a prospective, consecutive series of patients. Three tissue samples were obtained for culture from each graft at different time-intervals during the graft preparation. In addition, the erythrocyte sedimentation rate and the C-reactive protein level were evaluated preoperatively and on the third, seventh, and twentieth postoperative days, and the clinical course of all patients was monitored. The time needed for graft preparation was significantly longer for hamstring autografts (nineteen minutes) than for bone-patellar tendon-bone autografts (ten minutes) (p = 0.032). In the hamstring group, cultures of graft tissue from four patients (13%) were positive for bacteria. In the bone-patellar tendon-bone group, cultures of graft tissue from three patients (10%) were positive for bacteria; the difference between groups was not significant (p = 0.923). No patient had development of a postoperative infection. There were no differences between patients with a contaminated graft and those with an uncontaminated graft with regard to postoperative changes in the erythrocyte sedimentation rate or the C-reactive protein level at all time-intervals. A high rate (12%) of autograft contamination can be expected during autograft preparation for anterior cruciate ligament reconstruction. The contamination rate is almost equal for both bone-patellar tendon-bone and hamstring tendon autografts. We could not identify an association between contaminated grafts implanted in the knee and postoperative inflammatory markers such as the erythrocyte sedimentation rate and the C-reactive protein level.

Anterior Cruciate Ligament Reconstruction in Patients Who Have Excessive Joint Laxity

The purpose of the present study was to compare the clinical results of anterior cruciate ligament reconstruction with use of different grafts in patients with or without excessive joint laxity. We retrospectively studied eighty-three patients (forty-eight men and thirty-five women) who had undergone anterior cruciate ligament reconstruction between June 2002 and August 2004. Of the thirty-one patients who had generalized joint laxity, twenty were managed with an autologous bone-patellar tendon-bone graft and eleven were managed with a four-bundle hamstring (semitendinosus-gracilis tendon) graft. Of the fifty-two patients who had normal joint laxity, thirty-three were managed with a bone-patellar tendon-bone graft and nineteen were managed with a hamstring graft. Clinical results were evaluated by means of an examination at a minimum of twenty-four months after surgery. Among the patients who had normal joint laxity, the mean side-to-side difference in anterior tibial translation on testing with the KT-2000 arthrometer at a minimum of twenty-four months postoperatively was 2.7 +/- 1.9 mm in the bone-patellar tendon-bone graft group and 3.5 +/- 1.7 mm in the hamstring graft group. This difference was not significant. The mean Lysholm score was 91 +/- 7 points in the bone-patellar tendon-bone graft group and 85 +/- 10 points in the hamstring graft group (p = 0.492). The side-to-side difference in anterior translation had an inverse correlation with the Lysholm score (beta = -0.604, p < 0.001). Among the patients who had excessive joint laxity, the mean side-to-side difference in anterior tibial translation was 3.4 +/- 1.5 mm in the bone-patellar tendon-bone graft group and 4.5 +/- 2.0 mm in the hamstring graft group (p = 0.036). The mean Lysholm score was 89 +/- 7 points in the bone-patellar tendon-bone group and 79 +/- 12 points in the hamstring group (p = 0.015). The side-to-side difference in anterior translation had an inverse correlation with the Lysholm score (beta = -0.708, p < 0.001). In patients who have excessive joint laxity, the two-year outcomes of anterior cruciate ligament reconstruction with bone-patellar tendon-bone grafts are better than those with four-bundle hamstring grafts in terms of both side-to-side anterior laxity and clinical results.

Comparison of Clinical Results in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft and Using Achilles Tendon Allograft

Purpose: To compare clinical outcomes after arthroscopic ACL reconstruction using bone-patellar tendonbone autograft and using fresh-frozen Achilles tendon allograft. Materials and Methods: We enrolled 61 patients who underwent anterior cruciate ligament reconstruction by means of bone-patellar tendon-bone autograft or Achilles tendon allograft between March, 2002 and December, 2006. The bone-patellar tendon-bone group included 29 patients (mean age 30.4 years), and the Achilles tendon allograft group included 32 patients (mean age 32.5 years). The mean follow-up was 18.2 months and 25.7 months in each group, respectively. Preoperative and last follow-up clinical results were evaluated through physical examination, KT-2000 arthrometer, stress roentgenogram, IKDC knee rating system, and Lysholm knee score. Results: The mean side-to-side difference in anterior translation, as measured by KT-2000 arthrometer, was significantly improved from 6.4 mm±3.0 to 3.2 mm±1.9 in the bone-patellar tendon-bone group, and from 7.6 mm±3.1 to 2.9 mm±2.0 in the Achilles tendon allograft group (p＜0.001). The Achilles tendon allograft group improved more significantly than did the bone-patellar tendon-bone group (p=0.045). The mean side-to-side difference on stress roentgenogram was significantly improved from 5.3 mm±2.5 to 2.0 mm±2.1 in the bone-patellar tendon-bone group, and from 6.0 mm±3.4 to 2.2 mm±2.1 in the Achilles tendon allograft group (p＜0.001). There was no significant difference between the two groups. According to the IKDC knee rating system at last follow-up, 26 (89.7%) patients in the bone-patellar tendon-bone group and 28 (87.5%) patients in the Achilles allograft group were normal or nearly normal. The mean Lysholm knee score significantly improved from 69.9 to 90.2 in the bone-patellar tendon-bone group, and from 64.4 to 91.4 in the Achilles tendon allograft group (p＜0.001). Conclusion: Both bone-patellar tendon-bone and Achilles tendon allograft groups showed satisfactory clinical results, with no significant difference in outcomes between the groups. We suggest that both bone-patellar tendon-bone autograft and Achilles tendon allograft be considered as graft substitutes for anterior cruciate ligament reconstruction.

Anterior Cruciate Ligament Reconstruction

The bone-patellar tendon-bone has been widely used and considered a good graft source. The quadriceps tendon was introduced as a substitute graft source for bone-patellar tendon-bone. We compared the clinical outcomes of anterior cruciate ligament reconstructions using central quadriceps tendon-patellar bone and bone-patellar tendon-bone autografts. We selected 72 patients who underwent unilateral anterior cruciate ligament reconstruction using bone-patellar tendon-bone between 1994 and 2001 and matched for age and gender with 72 patients who underwent anterior cruciate ligament reconstruction using quadriceps tendon-patellar bone. All patients were followed up for more than 2 years. We assessed anterior laxity, knee function using the Lysholm and International Knee Documentation Committee scores, and quadriceps strength, the means of which were similar in the two groups. More patients (28 or 39%) in the bone-patellar tendon-bone group reported anterior knee pain than in the quadriceps tendon-patellar bone group (six patients or 8.3%). Anterior cruciate ligament reconstruction using the central quadriceps tendon-patellar bone graft showed clinical outcomes comparable to those of anterior cruciate ligament reconstruction using the patellar tendon graft, with anterior knee pain being less frequent in the former. Our data suggest the quadriceps tendon can be a good alternative graft choice. Level III Therapeutic study.

Muscle Strength Evaluations after ACL Reconstruction

The quadriceps and hamstring muscle strengths of 16 patients operated using a bone-patellar tendon-bone (BTB) autograft and 32 patients operated using a quadruple hamstring autograft for an arthroscopic anterior cruciate ligament (ACL) reconstruction were analyzed 4- to 7-years postoperatively. Standardized isokinetic testing, a clinical evaluation and instrumented assessment of knee laxity were done. The findings showed no significant strength deficits between the patients in the BTB and Hamstring groups and the deficits were, in general, small. The quadriceps and hamstring muscle strengths were better in patients with a longer than shorter follow-up and stable knees had less knee flexion torque deficit than unstable knees. Strength deficit was associated with lower Lysholm knee scores. The findings of this study showed that the muscle strengths of the operated limb had a positive association with the functional outcome of the knee in the long-term and support the use of active rehabilitation after ACL reconstruction.

A Prospective Randomized Study of Anterior Cruciate Ligament Reconstruction

Background Debate exists regarding the optimal graft for anterior cruciate ligament reconstruction. Few studies have compared the differences in outcome after reconstruction using similar fixation methods. Hypothesis Similar outcomes will be seen after anterior cruciate ligament reconstruction with bone-patellar tendon-bone or quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. Study Design Randomized controlled trial; Level of evidence, 1. Methods Ninety-nine patients were prospectively randomized to bone-patellar tendon-bone (46 patients) or quadruple-strand semitendinosus/gracilis (53 patients) reconstruction groups. The bone-patellar tendon-bone group had slightly lower preinjury Tegner scores (6.7 vs 7.1, P = .03); otherwise, the groups were similar. All surgeries were performed by a single surgeon using an endoscopic technique with bioabsorbable interference screw fixation. Patients were evaluated at 3, 6, 12, and 24 months. Results Forty-six bone-patellar tendon-bone and 50 quadruple-strand semitendinosus/gracilis patients were available at 24 months (97%). No differences in International Knee Documentation Committee grade, Lysholm score, Tegner activity level, range of motion, single-legged hop test, KT-1000 arthrometer manual maximum difference, Short Form-36, or patient knee rating were found. The bone-patellar tendon-bone group had better flexion strength in the operated leg than in the nonoperated leg (102% vs 90%, P = .0001), fewer patients complaining of difficulty jumping (3% vs 17%, P = .03), and a greater number of patients returning to preinjury Tegner level (51% vs 26%, P = .01). The quadruple-strand semitendinosus/gracilis group had better extension strength in the operated leg than in the nonoperated leg (92% vs 85%, P = .04), fewer patients with sensory deficits (14% vs 83%, P = .0001), and fewer patients with difficulty kneeling (6% vs 20%, P = .04). Both groups showed significant improvement in KT-1000 arthrometer manual maximum difference, Lysholm score, Tegner activity level, International Knee Documentation Committee grade, and patient knee rating score. Conclusions Good outcomes were seen in both the bone-patellar tendon-bone and quadruple-strand semitendinosus/gracilis groups. Subtle differences were noted between the groups, which may help guide optimal graft choice.

Functional Assessment and Muscle Strength Before and After Reconstruction of Chronic Anterior Cruciate Ligament Lesions

The goal of this study was to evaluate strength and functional capacity before and after anterior cruciate ligament (ACL) reconstruction to determine the influences of preoperative strength deficit, graft type, and gender, as well as their clinical relevance in predicting postsurgical recovery and determining the postoperative rehabilitation program. This was a retrospective review of prospectively collected uniform data from a group of 191 patients undergoing ACL reconstruction. We assessed functional capabilities and strength of the quadriceps and hamstring at 60 degrees/s and 180 degrees/s by use of a Cybex II dynamometer (Lumex, Ronkonkoma, NY) before and 6, 9, and 12 months after surgery. There was a preoperative quadriceps strength deficit and a decreased limb symmetry index in patients with an ACL deficiency. This strength deficit increased postoperatively, with the highest measured deficit occurring at 6 months postoperatively and a clear improvement from 6 to 12 months. Functional assessment showed identical development. There was a statistically significant relation between an increased quadriceps strength deficit preoperatively and poor early postoperative functional performance. For the bone-patellar tendon-bone (BPTB) group, there was an increased quadriceps strength deficit compared with the semitendinosus and gracilis tendon (STG) group, and the STG group had an increased hamstring strength deficit on postoperative testing. The postoperative hamstring strength deficit is significantly increased in female patients. All of these data suggest that quadriceps strength deficit is related to the ACL injury and is increased by ACL reconstruction. Even 1 year after ACL reconstruction, a quadriceps strength deficit of almost 20% persists. Flexion strength is within the normal range before and after surgery. These results are influenced by graft choice, with a higher quadriceps strength deficit for BPTB grafts. STG grafts induce a higher hamstring strength deficit compared with BPTB grafts. Functional assessment is improved at 9 and 12 months postoperatively compared with preoperatively regardless of graft type. However, an increased preoperative quadriceps strength deficit results in a lower limb symmetry index at 6 and 9 months postoperatively. Level IV, therapeutic case series.

Intraoperative Incidents and Complications in Primary Arthroscopic Anterior Cruciate Ligament Reconstruction

To analyze intraoperative incidents and complications in primary arthroscopic anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) and quadruple hamstring semitendinosus and gracilis (STG) grafts. From January 1999 to June 2004, we performed 330 BPTB and 96 STG procedures. Intraoperative incidents and complications were recorded for each case. Our overall intraoperative incident and complication rate was 9.6% and was higher in the STG group (13.5%) than in the BPTB group (8.7%). In the BPTB group, combined incidents and complications according to stage of the procedure consisted of graft harvesting, 4 cases (1.21%); tunnel placement, 9 cases (2.7%); and graft fixation, 15 cases (4.5%). In the STG group, combined incidents and complications included graft harvesting, 8 cases (8.3%); tunnel placement, 1 case (1%); graft fixation, 3 cases (3.1%); and others, 1 case (1%). In 4 patients (0.9%), we had to change the technique from BPTB to STG and vice versa. In 2 STG cases, conversion of the technique was required because of graft-related problems; in the third case, it was necessary because of fixation. One BPTB was converted to STG because the graft was completely transected as a result of improper screw fixation technique. None of the encountered incidents and complications had an adverse effect on final stability or on range of motion in operated knees. All incidents and complications were due to technical errors that occurred during graft harvesting, tunnel placement, or graft fixation. It is known that technical errors are preventable if careful surgical technique is followed. The surgeon must be well versed in various reconstruction techniques to be able to detect and resolve forthcoming incidents or complications. Backup implants are mandatory. IV, therapeutic case series.

A Comparison of Bone-Patellar Tendon-Bone and Bone-Hamstring Tendon-Bone Autografts for Anterior Cruciate Ligament Reconstruction

Background Most of the previous comparative studies between patellar tendon and hamstring tendon anterior cruciate ligament grafts compared grafts of different constructs fixed with different methods. Purpose To compare patellar tendon and hamstring tendon grafts with the same fixation method used to reconstruct the anterior cruciate ligament. Study Design Randomized controlled trial; Level of evidence, 1. Methods During the reconstructive procedure, the hamstring tendon graft was prepared as a bone-hamstring-bone graft; both bone-patellar tendon-bone and bone-hamstring-bone grafts were fixed with interference screws. Eighty consecutive patients who underwent anterior cruciate ligament reconstruction were randomly assigned to either bone-patellar tendon-bone or bone-hamstring-bone groups. Follow-up examinations were performed for at least 5 years postoperatively. Seventy-two of the 80 patients (37 patients in the bone-patellar tendon-bone group and 35 in the bone-hamstring-bone group) were evaluated, with a mean follow-up period of 87.0 and 80.8 months, respectively. Follow-up examinations were performed using the International Knee Documentation Committee knee ligament standard and subjective knee forms. Results The mean KT-1000 arthrometer evaluation results showed no significant difference between the bone-patellar tendon-bone and bone-hamstring-bone groups (1.2 ± 2.1 mm and 1.7 ± 1.4 mm, respectively; P =. 24). However, symptoms related to graft harvest (anterior kneeling pain) were more frequently observed in the bone-patellar tendon-bone group, and unsatisfactory results were correlated with severe kneeling pain in 3 patients from this group (P =. 0056). Significant hamstring muscle weakness without complaint of functional deficit was found in the bone-hamstring-bone group (P =. 0045). Conclusion Bone-hamstring-bone grafts were shown to reduce the risk of problems at the graft harvest site compared to bone-patellar tendon-bone grafts, with comparable results in the remaining clinical parameters tested.

Comparison of Arthroscopic Anterior Cruciate Ligament Reconstruction between Autologous Hamstring Tendonand Bone-patellar Tendon-bone Graft: Short Term FollowUp

Purpose : To evaluate the stability, activity level and clinical results of an autologous hamstring and Bone-patellar tendon-bone (BPTB) graft in an Anterior cruciate ligament (ACL) reconstruction. Materials and Methods : Between September 1997 and January 2003, 22 patients with an ACL reconstruction with an autologous four strand hamstring tendon, and 30 patients with a BPTB autograft were enrolled in this study. At the time of the final follow-up, the patients were evaluated by stress radiographs using a Telos instrument, the Lysholm score, Tegner activity score, IKDC activity grades, and anterior kneeling pain. Results : An evaluation of the anterior laxity using the Telos instrument revealed no significant difference in the hamstring and BPTB groups: side to side difference 2.6 mm in the hamstring group vs 2.3 mm in the BPTB groups (p＞0.05). The Lysholm score improved from a preoperative score of 58 to a postoperative score of 88 in the hamstring groups and from 56 to 91 in the BPTB groups. The Tegner score for the hamstring groups was 2.4 preoperatively and 5.8 at the final follow up, and the Tegner score for the BPTB groups were 2.3 and 6.2 preoperatively and after the last follow-up, respectively. The Tegner score was similar in the two treatment groups (p＞0.05). According to the IKDC rating system, 9% were normal and 64% were almost normal in the hamstring group. In the BPTB group, 10% were normal and 67% were almost normal. Anterior kneeling pain after a reconstruction with the hamstring tendon autograft (13%) was significantly less common than with the patellar tendon autograft (37%)(p＜0.05). Conclusion : The hamstring autograft for an ACL reconstruction decreased the incidence of anteriorkneeling pain and produced equivalent clinical results to the BPTB autograft.

Hamstring Tendon versus Patellar Tendon Anterior Cruciate Ligament Reconstruction Using Biodegradable Interference Fit Fixation

Background There are still controversies about graft selection for primary anterior cruciate ligament reconstruction, especially with respect to knee stability and functional outcome. Hypothesis Biodegradable interference screw fixation of hamstring tendon grafts provides clinical results similar to those achieved with identical fixation of bone-patellar tendon-bone grafts. Study Design Cohort study; Level of evidence, 2. Methods In 1996 and 1997, primary isolated anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft was performed in 72 patients. Since 1998, hamstring tendons were used as routine grafts. Matched patients with a hamstring tendon graft were selected from a database (n = 284). All patients were followed prospectively for a minimum of 2 years with KT-1000 arthrometer testing, International Knee Documentation Committee score, and Lysholm score. Results In the bone-patellar tendon-bone group, 9 patients were excluded because of bilateral rupture of the anterior cruciate ligament, 3 patients (4.2%) had a graft rupture, and 4 patients were lost to follow-up (follow-up rate, 92.1%), leaving 56 patients for a matched-group analysis. In the hamstring tendon database, the graft rupture rate was 5.6% (P = .698). The Lysholm score was 89.7 in the patellar tendon group and 94 in the hamstring tendon group (P = .003). The KT-1000 arthrometer side-to-side difference was 2.6 mm for the patellar tendon group and 2.1 mm for the hamstring tendon group (P = .041). There were significantly less positive pivot-shift test results in the hamstring tendon group (P = .005), and hamstring tendon patients showed lower thigh atrophy (P = .024) and patellofemoral crepitus (P = .003). Overall International Knee Documentation Committee scores were better (P = .001) in the hamstring tendon group (hamstring tendon: 34 × A, 21 × B, 0 × C, 0 × D; bone-patellar tendon-bone: 17 × A, 32 × B, 6 × C, 0 × D). Conclusions In this comparison of anterior cruciate ligament reconstruction with bone-patellar tendon-bone and anatomical hamstring tendon grafts, the hamstring tendon graft was superior in knee stability and function. These findings are partially contrary to previous studies and might be attributable to the use of an anatomical joint line fixation for hamstring tendon grafts. Thus, hamstring tendons are the authors’ primary graft choice for anterior cruciate ligament reconstruction, even in high-level athletes.

Anterior Cruciate Ligament Reconstruction

The choice of graft for anterior cruciate ligament reconstruction is a matter of debate, with patellar and hamstring tendons being the two most popular autologous graft options. The objective of this study was to determine in a prospective, randomized clinical trial whether two grafts (bone-patellar tendon-bone or doubled hamstring tendons) fixed with modern devices affect the two-year minimum clinical and radiographic outcomes of anterior cruciate ligament reconstruction.One hundred and twenty patients with a chronic unilateral rupture of the anterior cruciate ligament underwent arthroscopically assisted reconstruction with use of either autologous bone-patellar tendon-bone or doubled hamstring tendon grafts, in a strictly alternating manner. Both groups were comparable with regard to demographic data, preoperative activity level, mechanism of injury, interval between the injury and the operation, and the amount of knee laxity present preoperatively. The same well-proven surgical technique and aggressive controlled rehabilitation was used. An independent observer, who was blinded with regard to the involved leg and the type of graft, performed the outcome assessment with use of a visual analog scale, the new International Knee Documentation Committee form, the Knee Injury and Osteoarthritis Outcome Score, the Functional Knee Score for Anterior Knee Pain, and an arthrometric and an isokinetic dynamometric evaluation. Radiographs were also made.At the two-year follow-up evaluation, no differences were found in terms of the visual analog score, the Knee Injury and Osteoarthritis Outcome Score, the new International Knee Documentation Committee subjective and objective evaluation scores, the KT-1000 side-to-side laxity measurements, the Functional Knee Score for Anterior Knee Pain, muscle strength recovery, or return to sports activities. In the bone-patellar tendon-bone group, we found a higher prevalence of postoperative kneeling discomfort (p < 0.01) and an increased area of decreased skin sensitivity (p < 0.001). In the hamstring tendon group, we recorded a higher prevalence of femoral tunnel widening (p < 0.01). In this group, a correlation was also found between medial meniscectomy and an increased prevalence of pivot-shift glide (p = 0.035).We believe that, with use of accurate and proven surgical and rehabilitation techniques, both grafts are an equivalent option for anterior cruciate ligament reconstruction.