Anterior Cruciate Ligament reconstruction, hamstring versus bone–patella tendon–bone grafts: a systematic literature review of outcome from surgery
Introduction
The Anterior Cruciate Ligament (ACL) is regarded as critical to the normal functioning of the knee, its disruption causing functional impairment, meniscal lesions, and the early onset of joint degeneration [1]. Injury of the ACL is now the most common ligamentous injury of the knee and accounts for about 30 injuries per 100,000 of the population [2], with greater than 100,000 new ACL injuries occurring each year [3]. No definitive management strategy exists for patients with this injury, a case particularly evident when deciding between conservative rehabilitation and reconstruction, and between methods of reconstruction [4].
With surgical intervention, several surgical procedures are available including mini-arthrotomy open technique; two-incision arthoscopically assisted techniques, and one incision endoscopic technique [5]. Currently, ACL reconstruction is most often performed using an arthroscopically assisted technique [2]. Both biological and non-biological tissues can be used to provide the donor graft; these include patella tendon, semitendinosus/gracilis tendon, distal iliotibial tract, fascia lata and synthetic ligaments [2]. The biological tissue grafts are available either as autografts or allografts.
In recent years, central third of the patellar tendon (PT) and combined Semitendinosis and gracilis tendons (HT) have become the most frequently used graft types for anterior cruciate knee ligament reconstruction [6]. For the past two decades, the gold standard in ACL reconstructions has been the patellar tendon graft from the middle third of the patella tendon [7], but increasingly the HT graft has been used. This shift in popularity has occurred for several reasons, including, concerns about damaging the knee extensor apparatus using the patella tendon procedure and the potential for subsequent anterior knee pain, patella fracture, ligament rupture, and infra patella contraction [8]. Potential complications also exist with the hamstring techniques. Tunnel widening and fixation may be more of a problem in the hamstring procedure and there have been concerns about how the graft harvest procedure may affect the muscle function of the hamstring. When examining the literature though it would appear that the move towards hamstring graft has been achieved with little in the way of objective supporting data [8].
The best choice of tissue graft for use in ACL reconstruction has been the subject of much discussion. However, despite the amount of literature on ACL reconstruction and its outcome, there are very few clinically controlled, randomised studies directly comparing the two most commonly used tissue grafts, the bone–patella tendon–bone and the semitendinosus/gracilis tendon. Therefore this review aims to examine the data available from randomised trials, in order to combine and evaluate the best available evidence for choice between these two popular tissue grafts for use in ACL reconstruction.
The objective of this review was to assess the effectiveness of PT graft compared to HT graft as used in the treatment of ACL injuries of the knee. The null-hypothesis tested was that there is no difference in outcome between bone–patella tendon–bone (PT) graft versus semitendinosus and gracilis tendon (HT) graft.
Section snippets
Types of studies
Any randomised or quasi-randomised controlled trials, which evaluated surgical treatment of ACL injuries of the knee. A quasi-randomised trial refers to methods of allocating participants to a treatment, which are not strictly random (e.g. Date of Birth or alternation).
Types of participants
Adults/Teenagers of either sex, who have been diagnosed with an ACL injury in need of surgery.
Types of intervention
Trials comparing bone–patella tendon–bone graft to semitendinosus and gracilis (hamstring) tendon graft for reconstruction of ACL
Description of studies
Research for this review resulted in the identification of 52 studies, 13 of which met the inclusion criteria of the review. Thirty-four studies were excluded, eight studies failed due to type of graft used, 25 studies failed due to non-randomisation, and 5 studies failed due to non-comparison of bone–patella tendon–bone graft with semitendinosus/gracilis graft.
In the 13 trials included in this review, 1145 participants were involved, of these the majority were male adults. Where reported, the
Discussion
Arthroscopic reconstruction using either the PT or HT grafts has become a frequently used intervention for the repair of ACL injuries. The aim of this review was to evaluate the effectiveness of these two grafts by comparing the results of 8 specific outcomes in 13 randomised or quasi-randomised studies involving 1145 patients. The methodology of all 13 studies was considered flawed, particularly regarding the lack of blinding of allocation concealment, during treatment and outcome assessors,
Conclusion
The literature suggests that there continues to be much discussion regarding the ideal graft choice for ACL reconstruction. There are strong advocates for both PT and HT grafts, some suggesting that the PT provide better stability and others indicating lower incidence of PFP with the HT graft. The results of the 13 studies included in this review suggest that there is no significant evidence to indicate that one graft is more effective than the other. Both the PT and HT grafts appear to improve
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2017, Journal of Clinical Orthopaedics and TraumaCitation Excerpt :In anterior cruciate ligament (ACL) reconstruction, hamstring tendon grafts are replacing the popular bone-patellar tendon bone grafts that have been associated with femoro-tibial joint pain, loss of extension, and patellar tendon rupture.1–6