Document Title: Pinczewski-AJSM-Jul02.shtml
Article Title: A Five-Year Comparison of Patellar Tendon Versus Four-Strand Hamstring Tendon Autograft for Arthroscopic Reconstruction of the Anterior Cruciate Ligament
Authors: Leo A. Pinczewski, FRACS, David J. Deehan, MD, Lucy J. Salmon, BAppSci (Phty), Vivianne J. Russell, BSc (Biomed) and Amanda Clingeleffer, BAppSci
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: July 2002
Volume 30, pages 523-536
Keywords: ACL autografting, patellar-tendon versus hamstring, 5-year follow-up.

(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)

Comments: A superb and highly insightful study, accompanied by a penetratingly insightful discussion. With regards to being thorough in terms of controlling for the various factors germane to ACL-reconstruction outcome, and also with regards to having a sufficiently protracted follow-up time in the study (5 years is a reasonable minimum), the authors make the penetrating comment: "Despite the plethora of literature on ACL reconstruction, there are [as of early 2002] only three other scientifically valid reports that compare autograft patellar tendon with hamstring tendon graft constructs (Aglietti 1994, Marder 1991, and O'Neill 1996)... It would be inappropriate to extrapolate the results of one report to those of another unless account is taken of patient activity level, sex, age, timing of surgery, surgical technique, the rehabilitation program followed, and specific outcome measures." Using a 5-year follow-up, the authors found that patellar-tendon autografting and hamstring autografting bring similar results (despite the fact that the patellar-tendon autograft's bone plugs at both ends mean faster ligamentization). Regrettably, it seems that patellar-tendon autograft, in addition to resulting in pain while kneeling and lingering donor-site tenderness, can bring signs of osteopathic degeneration (in the tibiofemoral compartment) sooner than the hamstring autograft. However, it is worth keeping in mind that both options, by restoring knee stability, stop the damage that would be caused by regular giving-way and abnormal amounts of forwards tibial sliding. Granted, because of the bone-bruising and other damage which almost always tends to accompany full ACL tearing, any ACL-full-tearing knee will forever be more likely to develop premature osteoarthritis. But prompt reconstruction at least prevents further instability-induced damage. The reader should also keep in mind that hamstring autografting permanently reduces hamstring-group strength; this is worrisome because the hamstrings play a major role in protecting the ACL. Furthermore, the harvesting of the hamstring tendons results in a loss of terminal (end-range) flexion. (If you were to stand on one leg and pull your heel up towards your buttock, with a hamstring-type ACL graft you would no longer be able to pull your heel up as far. Although this active-range-of-motion deficit would not be overly noticeable in most activities, you would notice it if you were jumping over an obstacle.) In the end, there is no such thing as the perfect ACL graft; there is always a compromise to be made. Knee injuries are lifelong injuries; any person who incurs any type of complete (or severe partial) ACL tearing can expect to revisit the topic (or its aftermath) repeatedly as he/she subsequently progresses through life—irrespective of the reconstructive-surgery details. The authors observe that "the principal surgical determinants for outcome of ACL reconstruction are tunnel placement, graft choice, fixation choice, and type of postoperative rehabilitation program".

Note that the definition of "long-term" in follow-up is sometimes subject to interpretation. Given that knee injuries tend to bring lifelong consequences, and given that the average person who incurs an ACL injury probably has roughly a half-century of life expectancy remaining, it seems clear that a "long-term study" should refer to a time frame substantially longer than five years. Pinczewski et al. very wisely note that this five-year study qualifies as medium-term. They write: "Longitudinal medium-term follow-up has allowed us to identify new trends.... The fact that these patterns are not seen at the 2-year review highlights the need to redefine short-term follow-up at 3 years rather than 2 years for ACL reconstruction.". So, a 3-year follow-up is short term, and a 5-year follow-up is medium term. Logically, long-term follow-up from ACL reconstruction should be no less than 10 years, and ideally should extend until the patient requires a total knee replacement.

ABSTRACT

Background: The choice of graft material for anterior cruciate ligament reconstruction is believed to play a major role in outcome, but most comparisons of graft choice have not been well controlled.

Hypothesis: The choice of graft material (patellar tendon or hamstring tendon) does affect clinical outcome after anterior cruciate ligament reconstruction.

Study Design: Prospective, nonrandomized clinical trial.

Methods: Two groups of 90 patients each were followed for a minimum of 5 years.

Results: International Knee Documentation Committee assessment revealed that more than 85% of each group had an overall score of A or B at all follow-up intervals. The median Lysholm knee score was greater than 90 for both groups at 2 and 5 years. Instrumented testing revealed no significant difference between the two groups beyond 3 years. Thirty-one percent of the patellar tendon group (25) had a fixed flexion deformity and 19% of the hamstring tendon group (14) had fixed flexion deformity at 5 years. Radiologic assessment revealed early osteoarthritic changes in 4% of the hamstring tendon group (2) and in 18% of the patellar tendon group (11) at 5 years.

Conclusions: Arthroscopic reconstruction with either graft results in a similar surgical outcome, reliably restoring knee stability over a 5-year period; however, patients with patellar tendon grafts are at greater risk of developing early signs of osteoarthritis.

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