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Reconstruction of the Anterior Cruciate Ligament: Meta-analysis of Patellar Tendon Versus Hamstring Tendon Autograft

      Purpose: No graft tissue has consistently shown superiority over others for reconstruction of the anterior cruciate ligament (ACL). Bone–patellar tendon-bone (BPTB) and doubled hamstring tendon (semitendinosus and gracilis) (HT) are the most commonly used autologous grafts. We performed a meta-analysis to compare the effectiveness of ACL reconstruction using either BPTB or HT grafts. Type of Study: Systematic review and meta-analysis. Methods: We searched the MEDLINE database (1966 to April 2003) for English-language randomized or prospective studies comparing BPTB and 3- or 4-strand HT grafts used for ACL reconstruction. For inclusion, studies were required to follow identical rehabilitation protocols within each study, and provide subjective or objective outcome data after a minimum average 2-year follow-up. Comparison data between BPTB and HT for each identified outcome measure were combined using a random-effects model meta-analysis. Results: Eleven reports fulfilled the criteria for inclusion. Outcomes favoring BPTB were found in the following outcome measures: normal Lachman examination (relative risk [RR], 0.91; 95% confidence interval [CI], 0.83–0.99; P = .025), normal pivot-shift (RR, 0.94; 95% CI, 0.88–1.0; P = .067), KT-1000 manual-maximum side-to-side difference of ≤3 mm (RR, 0.75; 95% CI, 0.55–1.01; P = .057), and fewer reconstructions resulting in flexion loss >5° (RR, 1.41; 95% CI, 1.01–1.96; P = .04). Intermediate level laxity was more common with the HT graft, as shown by higher rates of abnormal Lachman >0 (RR, 1.22; 95% CI, 0.99–1.5; P = .06), pivot-shift >0 (RR, 1.3; 95% CI, 0.96–1.75; P = .09), and KT-1000 manual-maximum side-to-side differences >3 mm (RR, 1.64; 95% CI, 1.13–2.39; P = .01). Outcome measures that favored HT were absence of patellofemoral crepitance (RR, 1.08; 95% CI, 1.01–1.15; P = .03), fewer results with extension loss >5° (RR, 0.56; 95% CI, 0.3–1.03; P = .06), and kneeling pain. The incidence of instability, as defined by Lachman grade 2, pivot-shift grade 2, or KT-1000 manual-maximum side-to-side difference >5 mm, was not significantly different between the 2 grafts. All other outcome measures were not significantly different. Conclusions: The data presented in this meta-analysis show that the incidence of instability is not significantly different between the BPTB and HT grafts. However, BPTB was more likely to result in reconstructions with normal Lachman, normal pivot-shift, KT-1000 manual-maximum side-to-side difference <3 mm, and fewer results with significant flexion loss. In contrast, HT grafts had a reduced incidence of patellofemoral crepitance, kneeling pain, and extension loss. The choice of graft by the patient and surgeon must be individualized, and the results of this meta-analysis can aid in the decision by clarifying the risks and benefits of each surgical approach. Level of Evidence: Level I.

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      References

        • Freedman K.B.
        • D’Amato M.J.
        • Nedeff D.D.
        • Kaz A.
        • Bach B.R.
        Arthroscopic anterior cruciate ligament reconstruction.
        Am J Sports Med. 2003; 31: 2-11
        • Aune A.K.
        • Holm I.
        • Risberg M.A.
        • Jensen H.K.
        • Steen H.
        Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction.
        Am J Sports Med. 2001; 29: 722-728
        • Jansson K.A.
        • Linko E.
        • Sandelin J.
        • Harilainen A.
        A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction.
        Am J Sports Med. 2003; 31: 12-18
        • Pinczewski L.A.
        • Deehan D.J.
        • Salmon L.J.
        • Russell V.J.
        • Clingeleffer A.
        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. 2002; 30: 523-536
        • Shaieb M.D.
        • Kan D.M.
        • Chang S.K.
        • Marumoto J.M.
        • Richardson A.B.
        A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction.
        Am J Sports Med. 2002; 30: 214-220
        • Frank C.B.
        • Jackson D.W.
        Current concepts review—The science of reconstruction of the anterior cruciate ligament.
        J Bone Joint Surg Am. 1997; 79: 1556-1576
        • Fu F.H.
        • Bennett C.H.
        • Lattermann C.
        • Ma C.B.
        Current trends in anterior cruciate ligament reconstruction. Part I: Biology and biomechanics of reconstruction.
        Am J Sports Med. 1999; 27: 821-830
        • Fu F.H.
        • Bennett C.H.
        • Ma C.B.
        • Menetrey J.
        • Lattermann C.
        Current trends in anterior cruciate ligament reconstruction. Part II: Operative procedures and clinical correlations.
        Am J Sports Med. 2000; 28: 124-130
        • Hamner D.L.
        • Brown C.H.
        • Steiner M.E.
        • Hecker A.T.
        • Hayes W.C.
        Hamstring tendon grafts for reconstruction of the anterior cruciate ligament.
        J Bone Joint Surg Am. 1999; 81: 549-557
        • Graham S.M.
        • Parker R.D.
        Anterior cruciate ligament reconstruction using hamstring tendon grafts.
        Clin Orthop. 2002; 402: 64-75
        • Feagin Jr, J.A.
        • Wills R.P.
        • Lambert K.L.
        • Mott H.W.
        • Cunningham R.R.
        Anterior cruciate ligament reconstruction.
        Clin Orthop. 1997; 341: 69-72
        • O’Neill D.B.
        Arthroscopically assisted reconstruction of the anterior cruciate ligament.
        J Bone Joint Surg Am. 2001; 83: 1329-1332
        • Aglietti P.
        • Buzzi R.
        • Zaccherotti G.
        • De Biase P.
        Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction.
        Am J Sports Med. 1994; 22: 211-217
        • Aglietti P.
        • Zaccherotti G.
        • Buzzi R.
        • De Biase P.
        A comparison between patellar tendon and doubled semitendinosus/gracilis tendon for anterior cruciate ligament reconstruction.
        J Sports Traumatol. 1997; 19: 57-68
        • Corry I.S.
        • Webb J.M.
        • Clingeleffer A.J.
        • Pinczewski L.A.
        Arthroscopic reconstruction of the anterior cruciate ligament.
        Am J Sports Med. 1999; 27: 444-454
        • Ejerhed L.
        • Kartus J.
        • Sernert N.
        • Kohler K.
        • Karlsson J.
        Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction?.
        Am J Sports Med. 2003; 31: 19-25
        • Eriksson K.
        • Anderberg P.
        • Hamberg P.
        A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament.
        J Bone Joint Surg Br. 2001; 83: 348-354
        • Marder R.A.
        • Raskind J.R.
        • Carroll M.
        Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction.
        Am J Sports Med. 1991; 19: 478-484
        • Muneta T.
        • Sekiya I.
        • Ogiuchi T.
        • Yagishita K.
        • Yamamoto H.
        • Shinomiya K.
        Effects of aggressive early rehabilitation on the outcome of anterior cruciate ligament reconstruction with multi-strand semitendinosus tendon.
        Int Orthop. 1998; 22: 352-356
        • Anderson A.F.
        • Snyder R.B.
        • Lipscomb A.B.
        Anterior cruciate ligament reconstruction.
        Am J Sports Med. 2001; 29: 272-279
        • Beard D.J.
        • Anderson J.L.
        • Davies S.
        • Price A.J.
        • Dodd C.A.F.
        Hamstrings vs. patella tendon for anterior cruciate ligament reconstruction.
        Knee. 2001; 8: 45-50
        • Doral M.N.
        • Leblebicioglu G.
        • Atay O.A.
        • Baydar M.L.
        • Tetik O.
        • Atik S.
        Arthroscopy-assisted anterior cruciate ligament reconstruction with patellar tendon or hamstring autografts.
        Bull Hosp Jt Dis. 2000; 59: 81-87
        • O’Neill D.B.
        Arthroscopically assisted reconstruction of the anterior cruciate ligament.
        J Bone Joint Surg Am. 1996; 78: 803-813
        • Otero A.L.
        • Hutcheson L.
        A comparison of the doubled semitendinosus/gracilis and central third of the patellar tendon autografts in arthroscopic anterior cruciate ligament reconstruction.
        Arthroscopy. 1993; 9: 143-148
        • Sgaglione N.A.
        • Del Pizzo W.
        • Fox J.M.
        • Friedman M.J.
        Arthroscopically assisted anterior cruciate ligament reconstruction with the pes anserine tendons.
        Am J Sports Med. 1993; 21: 249-256
        • Steiner M.E.
        • Hecker A.T.
        • Brown C.H.
        • Hayes W.C.
        Anterior cruciate ligament graft fixation.
        Am J Sports Med. 1994; 22: 240-246
        • Barrett G.R.
        • Noojin F.K.
        • Hartzog C.W.
        • Nash C.R.
        Reconstruction of the anterior cruciate ligament in females.
        Arthroscopy. 2002; 18: 46-54
        • Fox J.A.
        • Nedeff D.D.
        • Bach B.R.
        • Spindler K.P.
        Anterior cruciate ligament reconstruction with patellar autograft tendon.
        Clin Orthop. 2002; 402: 53-63
        • Holmes P.F.
        • James S.L.
        • Larson R.L.
        • Singer K.M.
        • Jones D.C.
        Retrospective direct comparison of three intraarticular anterior cruciate ligament reconstructions.
        Am J Sports Med. 1991; 19: 596-600
        • Kartus J.
        • Movin T.
        • Karlsson J.
        Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts.
        Arthroscopy. 2001; 17: 971-980
        • Sachs R.A.
        • Daniel D.M.
        • Stone M.L.
        • Garfein R.F.
        Patellofemoral problems after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1989; 17: 760-765
        • Shino K.
        • Nakagawa S.
        • Inoue M.
        • Horibe S.
        • Yoneda M.
        Deterioration of patellofemoral articular surfaces after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1993; 21: 206-211
        • Brand Jr, J.
        • Hamilton D.
        • Selby J.
        • Pienkowski D.
        • Caborn D.N.M.
        • Johnson D.L.
        Biomechanical comparison of quadriceps tendon fixation with patellar tendon bone plug interference fixation in cruciate ligament reconstruction.
        Arthroscopy. 2000; 16: 805-812
        • Harter R.A.
        • Osternig L.R.
        • Standifer L.W.
        Isokinetic evaluation of quadriceps and hamstrings symmetry following anterior cruciate ligament reconstruction.
        Arch Phys Med Rehabil. 1990; 71: 465-468
        • Rosenberg T.D.
        • Franklin J.L.
        • Baldwin G.N.
        • Nelson K.A.
        Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction.
        Am J Sports Med. 1992; 20: 519-525
        • Yunes M.
        • Richmond J.C.
        • Engels E.A.
        • Pinczewski L.A.
        Patellar versus hamstring tendons in anterior cruciate ligament reconstructions.
        Arthroscopy. 2001; 17: 248-257
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Webster K.E.
        • Feller J.A.
        • Hameister K.A.
        Bone tunnel enlargement following anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2001; 9: 86-91
        • Woo S.L.
        • Hollis J.M.
        • Adams D.J.
        • Lyon R.M.
        • Takai S.
        Tensile properties of the human femur-anterior cruciate ligament-tibia complex.
        Am J Sports Med. 1991; 19: 217-225
        • Noyes F.R.
        • Butler D.L.
        • Grood E.S.
        • Zernicke R.F.
        • Hefzy M.S.
        Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.
        J Bone Joint Surg Am. 1984; 66: 344-352
        • Cooper D.E.
        • Deng X.H.
        • Burstein A.L.
        • Warren R.F.
        The strength of the central third patellar tendon graft.
        Am J Sports Med. 1993; 21: 818-823
        • Shelbourne K.D.
        • Trumper R.V.
        Preventing anterior knee pain after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1997; 25: 41-47
        • Kocher M.S.
        • Steadman J.R.
        • Briggs K.
        • Zurakowski D.
        • Sterett W.I.
        • Hawkins R.J.
        Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction.
        J Bone Joint Surg Am. 2002; 84: 1560-1572