|Year : 2021 | Volume
| Issue : 2 | Page : 48-52
Comparison of doubled semitendinosus and gracilis autograft versus bone-patellar tendon-bone autograft for reconstruction of the anterior cruciate ligament
Navin Kumar Karn1, Bibhuti Nath Mishra2, Ranjib Kumar Jha3
1 Department of Orthopaedics, Neuro Cardio & Multispeciality Hospital, Biratnagar, Nepal
2 Department of Orthopaedics, Birat Medical College Teaching Hospital, Biratnagar, Nepal
3 Department of Orthopaedics, Nobel Medical College Teaching Hospital, Biratnagar, Nepal
|Date of Submission||16-Nov-2021|
|Date of Decision||22-Nov-2021|
|Date of Acceptance||25-Nov-2021|
|Date of Web Publication||20-Dec-2021|
Bibhuti Nath Mishra
Department of Orthopaedics, Birat Medical College Teaching Hospital, Tankisinwari, Biratnagar.
Source of Support: None, Conflict of Interest: None
Background: The choice of graft for anterior cruciate ligament (ACL) reconstruction is a matter of debate with hamstring and bone-patellar tendon-bone being the most popular autologous graft options. Objective: The objective of this study was to conduct a prospective randomized control trial comparing doubled semitendinosus and gracilis graft versus bone-patellar tendon-bone graft. Materials and Methods: Sixty patients with chronic unilateral rupture of ACL underwent arthroscopically assisted ACL reconstruction using quadrupled hamstring and bone-tendon-bone graft after randomization. Both groups were comparable with demographic data, preoperative activity level, mechanism of injury, the interval between injury and operation, and preoperative laxity of the knee. The same well-proved surgical technique and aggressive rehabilitation were used in all cases. The outcome assessment was done using the visual analog scale, Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) evaluation system. Results: At 2-year follow-up, we found that results within the same groups showed statistically significant improvement as assessed by IKDC, Tegner’s, and Lysholm operative scores. There was also a significant correlation between the manual Lachman test and stress laxometry findings. There was no statistically significant difference between the scores of the two groups (hamstring and bone patella tendon). In the hamstring group, we recorded a higher incidence of femoral tunnel widening, and in the bone-patellar tendon-bone group the higher incidence of kneeling discomfort and increased area of decreased sensation in the skin. Conclusions: Arthroscopic ACL reconstruction by either hamstring tendon graft or bone-patellar tendon-bone graft gives equally satisfactory results.
Keywords: Anterior cruciate deficient knee, bone patella bone graft, hamstring graft
|How to cite this article:|
Karn NK, Mishra BN, Jha RK. Comparison of doubled semitendinosus and gracilis autograft versus bone-patellar tendon-bone autograft for reconstruction of the anterior cruciate ligament. Int J Orthop Surg 2021;29:48-52
|How to cite this URL:|
Karn NK, Mishra BN, Jha RK. Comparison of doubled semitendinosus and gracilis autograft versus bone-patellar tendon-bone autograft for reconstruction of the anterior cruciate ligament. Int J Orthop Surg [serial online] 2021 [cited 2022 Nov 26];29:48-52. Available from: https://www.ijos.in/text.asp?2021/29/2/48/332934
| Introduction|| |
Due to the rising interest in sports these days, the injury to anterior cruciate ligament (ACL) has increased. Rupture of ACL may lead to instability, pain, swelling, mechanical dysfunction, and an increased risk of meniscal injury and degenerative changes.,,,, The goals of the ACL reconstruction are to restore the knee stability for normal activities and sports, to delay the onset of osteoarthritis, and to prevent the loss of meniscal functions. The choice of graft for ACL reconstruction is a matter of debate, although hamstring and bone-patellar tendon-bone (BPTB) are the most popular autologous graft options. The objective of this study was to conduct a prospective randomized control trial comparing doubled semitendinosus and gracilis graft versus BPTB graft.
| Materials and Methods|| |
From January 2012, a total of 60 patients with chronic unilateral rupture of ACL presenting to our department were included in the study. They were assessed by the Lachman test, anterior drawer test, pivot shift test clinically, and confirmed with magnetic resonance imaging (MRI). Patients who were adolescents with open physis, those who were over 40 years old, patients with a complaint of patellofemoral symptoms, patients with an acute lesion (less than 6 weeks of injury), patients who were associated with other ligament injuries, and those who underwent a previous surgery in the knee were excluded from the study. Ethical approval was obtained from the institutional ethical board. All patients were informed about the study procedure, the purpose of the study, and known risks. Written informed consent was obtained from each patient. The patients were randomly divided into two groups: the first group treated with hamstring graft and the other with BPTB graft. There were 30 patients in each group.
The ACL was reconstructed using the arthroscopically assisted technique. To standardize the technique, we adopted Larson and Kweon technique for hamstring tendon autograft and Gale et al.’s technique for BPTB autograft. Prophylactic antibiotic ceftriaxone was given before the skin incision.
The hamstring tendons were harvested through a small longitudinal anteromedial incision over the pes anserine insertion. The graft was then prepared for a quadrupled semitendinosus-EndoButton (Smith & Nephew Endoscopy, Massachusetts) construct using the Acufex Graft Master Table (AcufexMicrosurgicals, Massachusetts) construct.
The BPTB autograft was harvested via a 4–5 cm longitudinal incision over the patellar tendon and was prepared into a proper construct.
The portals used for arthroscopy included the anterolateral for arthroscope and anteromedial for instruments. The notch was prepared using a curette and motorized shaver until over the top position and femoral ACL footprint was shown. Routine notchplasty was not performed. The anteromedial portal was used for femoral tunnel preparation. The remnant of the ACL stump was used as a guide for the femoral tunnel. The femoral tunnel was reamed according to the size of the graft. The tibial stump was cleaned leaving a short amount of stump for referencing and graft coverage. Using Acufex elbow tipped tibial guide, the tibial guide pin was inserted to the posterior half of the remnant and the tibial tunnel was reamed according to the diameter of the graft. The depth of the tunnel was 26 mm for the hamstring EndoButton and 30 mm for the patellar tendon. In the case of the hamstring tendon, the outer femoral cortex was drilled with a 4.5-mm drill bit, and the femoral channel length was measured with a depth probe for the EndoButton setting. Using a suture passing pin, the suture was passed through the anteromedial portal and one end of the suture was withdrawn from the tibial tunnel with the help of a grasper. The passing suture was used to pass graft from the tibial tunnel into the femoral tunnel.
The fixation method for patellar tendon graft was a cannulated interference screw (Smith & Nephew) usually 7 mm × 20 mm. The femoral site was fixed at 120° knee flexion with the screw guide passed through the anteromedial portal. After femoral fixation, a good amount of tension was applied to the tibial bone block suture and the knee passed through several cycles of flexion-extension to pretension the graft. The tibial site was fixed in 20° knee flexion.
For the femoral fixation of the hamstring graft, the EndoButton was deployed at the outer femoral cortex when the second mark on the graft was flushed with the femoral tunnel opening. The graft was pulled back to confirm the EndoButton deployment. No further graft pretension was needed. The tibial site was fixed with sutures to the post technique at 20° knee flexion.
After the procedure, an intraarticular vacuum drain was placed through the anterolateral portal into the joint. The drain was removed at 24–48 h postoperatively. The knee was placed in a compression dressing and hinged knee brace locked in full extension.
Postoperatively the knee was unlocked to allow 0°–90° motion on the second and third postoperative days, and the patient was discharged. Weight-bearing was allowed as tolerated with axillary crutches but delayed with a concomitant meniscal repair. Full weight-bearing without support was allowed as soon as the patients were comfortable. All patients were followed at 2 weeks for wound inspection and suture removal and 6 weeks for brace removal. Wall sliding and semi-squats were allowed as the pain started improving. Bicycling was allowed at 2–3 months and general strengthening exercises continued. Returning to sports involving jumping, pivoting, or side-stepping was prohibited until 9 months postoperatively but with variable patient compliance.
All the patients were followed up initially by the operating surgeon. All final clinical testings and evaluations were performed by another independent surgeon. The evaluation included a supine range of motion measurements with goniometer, thigh circumference measurements, effusion, joint line tenderness, Mc Murrays test, and patellofemoral crepitation, as well as checking for associated complications. Stability testing included the Lachman test, anterior drawer test, posterior drawer test, pivot shift test, and valgus and varus stress test at 0° and 30° flexion. Ligamentous laxity was graded as 1+ (0–5 mm), 2+ (6–10 mm), and 3+ (more than 10 mm). The pivot shift was graded as 1+ (slip), 2+ (definite movement, jump), and 3+ (transient lock). A single-legged hop for distance was used for functional testing. The test was performed three times and averaged. The outcome assessment was done using the visual analog scale (VAS), Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) evaluation system.
The data were entered using Microsoft Excel software, version 8.0. The success of randomization was tested by comparing descriptive variables such as age, gender, the interval between injury and surgery. The t test was used to compare age and chi-square test for comparison of gender. Fisher’s exact test was used to compare the number of associated injuries and concomitant surgeries in both groups. The comparison of pre- and postoperative data within the group was made using Wilcoxon’s signed-rank test. The Mann–Whitney U test was used to compare variables between the two groups. A value of P < 0.05 was considered statistically significant.
| Results|| |
There were 30 patients in both groups. Both the groups were comparable in age and sex [Table 1]. There was also no difference in type and number of associated injuries and concomitant surgeries [Table 2]. Clinically, Lachman and Pivot shift tests were used for stability testing. There were no differences in the number and the distribution of grading of instability in both groups, both preoperatively and postoperatively [Table 3]. Both groups showed a significant improvement in instability.
Lysholm knee score, Tegner score, IKDC score, and pain assessment by VAS showed significant improvement from preoperative and final follow-up at 2 years. But there was no significant difference between both the groups except the IKDC score that favored the hamstring group [Table 3]
A total of 20 (66.66%) patients in the BPTB group experienced temporary numbness lateral to the skin incision but there was no sign of neuroma complication. All numbness completely recovered within a year. One patient in the BPTB group developed septic arthritis that required arthroscopic debridement and intravenous antibiotic. No significant complication was noted in the hamstring group.
| Discussion|| |
We observed that both hamstring and BPTB could effectively improve knee stability and function after ACL reconstruction. At the final follow-up of 2 years, the Lysholm knee score, Tegner score, IKDC score, and pain assessment by VAS showed a similar outcome. Although IKDC had been significantly improved from preoperative values in both groups, it was significantly higher in the hamstring group. However, the higher postoperative IKDC score in the hamstring group should be considered as only significant statistically and not clinically as both scores 95 and 96 were considered as an excellent result. Corry et al. found that the two grafts did not differ in terms of clinical stability, the range of motion, and general symptoms. Less thigh atrophy in the hamstring group was seen in the first year but there was no difference by the end of 2 years. The hamstring tendon group also had a lower graft harvest site morbidity. Akgün et al. found that the best results could be obtained if the reconstruction was done in the subacute period between 3 and 5 weeks post injury. They used BPTB graft for arthroscopic ACL reconstruction. One of the major drawbacks of the BPTB graft is “donor site morbidity.” All patients in the BPTB group in our study have experienced a disturbance of anterior knee sensation, which continued for a while, although it returned to normal within 1 year of follow-up period. However, no sensory disturbance was noted in the hamstring group. The scar is of smaller size in the hamstring group as compared to the BPTB group.
We found many prospective randomized control studies comparing two groups published in recent years. Results from these studies showed that the two groups had a similar outcome at the 2–5 years period.,,,, On the contrary, with similar studies Beynnon et al. found after 3 years of follow-up, the objective results of ACL reconstruction with a BPTB were superior to those of reconstruction with a two-strand semitendinosus gracilis tendon graft concerning knee laxity, pivot shift grade, and strength of the knee flexor muscle. In terms of patient satisfaction, activity level, and knee functions, our study had comparable results between the two groups.
From the most recent literature review, the authors found only two reports of the meta-analysis regarding the choice of graft for ACL reconstruction. Yunes et al. were the first to report a meta-analysis conducted from controlled trials of patellar tendon versus hamstring tendon for ACL reconstruction. They found that the patellar tendon patients had a greater chance of attaining a statically stable knee and an approximately 20% greater chance of returning to pre-injury activity levels. They concluded that although both techniques yielded good results, patellar tendon reconstruction led to higher postoperative activity levels and greater static stability than hamstring reconstruction. Freedman et al. found that the rate of graft failure in the patellar tendon group was significantly lower. There was a higher rate of manipulation under anesthesia or lysis of adhesions and anterior knee pain in the patellar tendon group and a higher incidence of hardware removal in the hamstring tendon group. They concluded that patellar tendon autografts had a significantly lower rate of graft failures and resulted in better knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstruction resulted in an increased rate of anterior knee pain.
Arthroscopic ACL reconstruction by either hamstring tendon graft or BPTB graft gives equally satisfactory results.
Data availability statement
The datasets used and analyzed during this study are available from the corresponding author (Bibhuti Nath Mishra, email: [email protected]) on reasonable request.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arnold JA, Coker TP, Heaton LM, Park JP, Harris WD. Natural history of anterior cruciate tears. Am J Sports Med 1979;7:305-13.
Drogset JO, Grøntvedt T. Anterior cruciate ligament reconstruction with and without a ligament augmentation device: Results at 8-year follow-up. Am J Sports Med 2002;30:851-6.
Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med 1976;4:95-100.
Hawkins RJ, Misamore GW, Merritt TR. Followup of the acute nonoperated isolated anterior cruciate ligament tear. Am J Sports Med 1986;14:205-10.
Jacobsen K. Osteoarthritis following insufficiency of the cruciate ligaments in man: A clinical study. Acta Orthop Scand 1977;48:520-6.
Dye SF, Wojtys EM, Fu FH, Fithian DC, Gillquist I. Factors contributing to function of the knee joint after injury or reconstruction of the anterior cruciate ligament. Instr Course Lect 1999;48:185-98.
Larson RV, Kweon C. Anterior cruciate ligament reconstruction with hamstring tendon autograft and EndoButton femoral fixation. Technique Knee Surg 2005;4:36-46.
Gale TM, Richmond JC, Patellar B. Tendon bone anterior cruciate ligament reconstruction. Technique Knee Surg 2006;5:72-9.
Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:444-54.
Akgün I, Ogüt T, Kesmezacar H, Yücel I. Central third bone-patellar tendon-bone arthroscopic anterior cruciate ligament reconstruction: A 4-year follow-up. J Knee Surg 2002;15:207-12.
Ejerhed L, Kartus J, Sernert N, Köhler K, Karlsson J. 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 2003;31:19-25.
Jansson KA, 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;31:12-8.
Pinczewski LA, Deehan DJ, Salmon LJ, Russell VJ, 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;30:523-36.
Anderson AF, Snyder RB, Lipscomb AB Jr. Anterior cruciate ligament reconstruction: A prospective randomized study of three surgical methods. Am J Sports Med 2001;29:272-9.
Eriksson K, Anderberg P, Hamberg P, Löfgren AC, Bredenberg M, Westman I, et al
. A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 2001;83:348-54.
Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renstrom P. Anterior cruciate ligament replacement: Comparison of bone-patellar tendon-bone grafts with two strand hamstring grafts. J Bone Joint Surg (Am) 2002;84:1503-13.
Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2001;17:248-57.
Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: A metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31:2-11.
[Table 1], [Table 2], [Table 3]