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ACL Reconstructions via Patellar-Tendon Autografts (includes also Quadriceps Tendon Autografts)
For articles focusing on graft-fixation devices, see ACL Reconstructions via Soft-Tissue (e.g. Hamstring) Autografts.
For a brief overview of knee anatomy, physiology, and biomechanics, please click here.
For articles specifically addressing the topic of revision ACL reconstructions, please see Revision Reconstructions: Factors behind ACL-Graft Failures, Outcomes.
For articles focusing on ACL reconstruction in degenerate knees, please see ACL Reconstruction in the Arthritic Knee.
Articles comparing single- versus double-bundle ACL grafting can be found under Choosing a Knee-Ligament Graft.
For a good discussion on the biomechanical shortfalls of the traditional single-bundle ACL graft, and for a good discussion on why dual-bundle ACL grafting is ultimately the way of the future (albeit there are some technical-logistical aspects that need to be addressed first, keeping in mind that double-bundle grafting increases the worries of surgeon error because this technique requires more bone-tunnel-drilling alignment finagling, and keeping in mind that incorrect bone-tunneling [hence surgeon error] is still the major cause of ACL-graft failure), please see the superb February 2007 article Effectiveness of Reconstruction of the Anterior Cruciate Ligament With Quadrupled Hamstrings and Bone-Patellar Tendon-Bone Autografts -- An In Vivo Study Comparing Tibial Internal-External Rotation, by Vasileios Chouliaras et al., in the Knee Biomechanics, Functional Anatomy of ACL and Other Ligaments Subsection, as well as the other articles linked to by that article.
Magnetic Resonance Imaging Analysis of Bioabsorbable Interference Screws Used for Fixation of Bone–Patellar Tendon–Bone Autografts in Endoscopic Reconstruction of the Anterior Cruciate Ligament, Jon Olav Drogset et al., American Journal of Sports Medicine, Baltimore, Maryland; July 2006, Vol 34, pages 1164-1169. Comments: These authors, who in a previous study found that metal interference screws are preferable to bioabsorbable ones, found that at 24 months post-op, volumetrically one-third of a bioabsorbable screw remains. The concerns with bioabsorbable screws are tunnel widening, formation of fluid pockets, and osteolysis; however, symptoms of problems are rare. And fortunately, the security and dependability of bone-to-bone healing, an advantage unique to the patellar-tendon autograft due to the bone plugs at both ends, remains. But if the person requires an ACL revision reconstruction, then the aforementioned concerns should be kept in mind. It should be kept in mind that, in the event of revision reconstruction being needed, metal interference screws can present problems too: the hardware might have to be removed, and bone-grafting done, before the revision itself can proceed. (Once again, we see the importance of doing ACL reconstruction correctly the first time. The major cause of graft failure is surgeon error, usually in the form of mis-placed bone tunnels. However, reinjury is distressingly common. Common causes of reinjury are failure to follow the rehabilitation protocol, failure to learn to pivot on only the front portion of the foot, and contact-type situations such as sideways forcing and injurious hyperextension.)
A Sixteen-Year Follow-up of Three Operative Techniques for the Treatment of Acute Ruptures of the Anterior Cruciate Ligament, Jon Olav Drogset et al., Journal of Bone and Joint Surgery, American Edition; June 2006, Vol 88, pages 944-952. Comments: This Norwegian study follows up on patients treated surgically for ACL injuries. The 16-year time span captures patients treated with no-longer-used techniques, most notably the ill-fated LAD (ligament augmentation device, a synthetic device which was later found to mechanically break down inside the knee and cause massive problems) and primary repair (i.e. suturing the torn ends of the ACL together). The surgeons found that the most successful reconstructions were those using the patellar-tendon (BTB) graft. (These surgeons use a slight variation of the standard patellar-tendon graft: they retain the remnants of the natural ACL and suture them to the graft. This method may bring a slight advantage over removing the entire natural ACL stumps because the flared-end contouring of the natural ACL seems to be preserved.) It would have been interesting if the authors would have done hamstring-graft ACL reconstructions too, just to provide a comparison standpoint with the patellar-tendon reconstruction. (This article includes a commentary by Cohen and Fu.)
For insight into ACL revision reconstruction using quadriceps tendon-patellar-bone autografting, see the April 2006 article Anterior Cruciate Ligament Revision Reconstruction -- Results Using a Quadriceps Tendon–Patellar Bone Autograft , by Noyes and Barber-Westin, in the Revision Reconstructions: Factors behind ACL-Graft Failures, Outcomes Subsection.
For a comparison of hamstring versus patellar-tendon autografts, both using interference-screw fixation, please see the February 2006 article A Comparison of Bone–Patellar Tendon–Bone and Bone–Hamstring Tendon–Bone Autografts for Anterior Cruciate Ligament Reconstruction, by Akio Matsumoto et al., in the Choosing a Knee-Ligament Graft Subsection.
Technical Note -- Anatomically Oriented Anterior Cruciate Ligament Reconstruction with a Bone–Patellar Tendon–Bone Graft via Rectangular Socket and Tunnel: A Snug-fit and Impingement-Free Grafting Technique, Konsei Shino et al., Arthroscopy: The Journal of Arthroscopic & Related Surgery; November 2005, Vol 21, p. 1402e2-1402e5. Comments: These authors describe a surgical technique refinement that enables a snug fit of the graft to be obtained in both the femoral and tibial tunnels.
Clinical Sports Medicine Update: Treatment of Anterior Cruciate Ligament Injuries, Part 2, Bruce D. Beynnon et al., The American Journal of Sports Medicine, Baltimore; November 2005, Vol 33, p. 1751-1767. Comments: This excellent article, in building on the solid foundation of part 1, expounds on the technical aspects of ACL surgery and follow-up aspects (including unbidden bone-tunnel widening, ligamentization of the graft, post-surgery rehabilitation, and potential confounding factors). The authors reviewed an absolutely astounding 3810 ACL-related studies published since 1994. They make a number of very astute observations, and note the importance of the services of a seasoned physiotherapist.
Clinical Sports Medicine Update: Treatment of Anterior Cruciate Ligament Injuries, Part 1, Bruce D. Beynnon et al., The American Journal of Sports Medicine, Baltimore; October 2005, Vol 33, p. 1579-1602. Comments: This article provides a very comprehensive overview (with a staggering 307 references) of ACL injuries and related aspects (including bone-bruising, meniscal damage, and concomitant ligamenous injuries). It also delves into risk factors (such as being a female athlete) and confounding factors (such as being someone with open growth plates [i.e. a child]). Beynnon et al. do a superb job of tying together all the various issues that must be considered when making decisions (e.g. to pursue surgery or not, and if so, what operations to do) pertinent to knee conditions, and they note the many interdependencies and complexities inherent in knee injuries (e.g. if the knee harbours damage to the posterolateral structures in addition to a torn ACL, then merely reconstructing the ACL is almost guaranteed to result in failure). The authors also provide interesting comparisons between the various options for ACL reconstruction, and they note that because ACL injuries rarely occur in isolation (i.e. concomitant injuries are very common), the eventual long-term outcome of any ACL treatment varies from person to person. They note that over 100,000 ACL reconstructions are performed annually in the United States alone (which works out to roughly 2000 of these surgeries each week).
For insight into the issue of ACL graft type (allograft versus autograft, both patellar-tendon-sourced), please see the October 2005 article Anterior Cruciate Ligament Reconstruction in Patients Older Than 40 Years Allograft Versus Autograft Patellar Tendon, by Gene Barrett et al., in the ACL Injuries and Surgeries in Patients Over 40 Years of Age Subsection.
Endoscopic Reconstruction of the Anterior Cruciate Ligament Using Bone–Patellar Tendon–Bone Grafts Fixed With Bioabsorbable or Metal Interference Screws -- A Prospective Randomized Study of the Clinical Outcome , Jon Olav Drogset et al., The American Journal of Sports Medicine, Baltimore; August 2005, Vol 33, p. 1160-1165. Comments: The patellar tendon autograft is invariably installed with the use of interference screws. This study compared bioabsorbable against metal ones, and found that the latter tend to bring predictably superior results. Bioabsorbable screws bring the concerns of osteolysis, bone-tunnel widening, and formation of fluid pockets. However, these rarely bring symptomatic problems. The secure bone-to-bone healing of the patellar-tendon autograft remains its clear and unique advantage. Imaging considerations pertaining to bioabsorbable screws, especially for the case in which revision reconstruction is being contemplated, can be found in the follow-up article.
For insight into the advantages of autografting over allografting, in particular with regards to patellar-tendon-type grafts, see the August 2005 article Clinical Comparison of the Tutoplast Allograft and Autologous Patellar Tendon (Bone–Patellar Tendon–Bone) for the Reconstruction of the Anterior Cruciate Ligament: 2- and 6-Year Results, by Ottmar Gorschewsky et al., in the Choosing a Knee-Ligament Graft Subsection.
For a meta-analysis-type update on the ACL-recon-via-patellar-tendon-versus-hamstring debate, please see the December 2004 article Clinical Sports Medicine Update -- Anterior Cruciate Ligament Reconstruction Autograft Choice: Bone-Tendon-Bone Versus Hamstring -- Does It Really Matter? A Systematic Review, by Kurt P. Spindler et al., in the Choosing a Knee-Ligament Graft Subsection.
Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts, Kazunori Yasuda et al., Arthroscopy: The Journal of Arthroscopic & Related Surgery; December 2004, Vol 20, p. 1015-1025. Comments: These authors found that double-bundle ACL reconstruction is clinically practical to perform. They found the results to be superior, and they note that the 2-bundle procedure displayed a better trend with respect to anterior stability in manual knee laxity tests. They also found that, in their KT-2000 arthrometer testing, fewer patients experienced graft failure (defined as greater than 5 mm of anterior drawer measured).
For a comparison of the patellar-tendon versus the hamstring autograft, please see the October 2004 article Anterior Cruciate Ligament Reconstruction: Bone-Patellar Tendon-Bone Compared with Double Semitendinosus and Gracilis Tendon Grafts -- A Prospective, Randomized Clinical Trial, by Paolo Aglietti et al., in the Choosing a Knee-Ligament Graft Subsection.
For a penetratingly insightful medium-term comparison of the two most common autografting options, please see the July 2002 article A Five-Year Comparison of Patellar Tendon Versus Four-Strand Hamstring Tendon Autograft for Arthroscopic Reconstruction of the Anterior Cruciate Ligament, by Leo A. Pinczewski et al., in the Choosing a Knee-Ligament Graft Subsection.
The Elongation Behaviour of the Anterior-Cruciate-Ligament Graft in vivo., Bruce D. Beynnon, The American Journal of Sports Medicine, Baltimore; Mar/Apr 2001, Vol 29/2, p. 161. Comments: This article documents the medium-term (5 years post-op) behaviour of patellar-tendon grafts.
Dr. F.L. Avery's concise and pragmatic synopsis of ACL-graft options can be found under Choosing a Knee-Ligament Graft.
Dynamic function after anterior cruciate ligament reconstruction with autologous patellar tendon , Charles A. Bush-Joseph; The American Journal of Sports Medicine, Baltimore; Jan/Feb 2001, Vol 29/1, p. 36. Comments: This article looks at the outcome of patellar-tendon-graft ACL reconstructions, and delves into the interrelated topics of quadriceps and hamstring strength.
The incidence of patellofemoral osteoarthritis and associated findings 7 years after anterior-cruciate-ligament reconstruction with bone-patellar-tendon-bone autograft , Timo Jarvela; The American Journal of Sports Medicine, Baltimore; Jan/Feb 2001, Vol 29/1, p. 18. Comments: This article discusses problems related chiefly to the patellar-tendon-graft harvesting process. Jarvela notes that in the follow-up study, tibiofemoral-compartment osteoarthritic changes were rare. The major problem observed was due to shortening of the patellar tendon. (Good post-surgery rehabilitation, including appropriate early mobilization and exercises, is the most essential preventive measure.)
Primary anterior cruciate ligamentreconstruction using the contralateral autogenous patellar tendon, Donald Shelbourne; The American Journal of Sports Medicine, Baltimore; Sep/Oct 2000, Vol 28/5, p. 651. Comments: Shelbourne discusses his contralateral bone-patellar-tendon-bone graft. He has found that taking the graft from the unaffected knee brings about faster rehabilitation than the traditional ipsilateral graft-harvesting procedure.
For penetrating insight into the neuromuscular consequences of ACL injuries, see the May 2000 article Longitudinal effects of anterior-cruciate-ligament injury and patellar-tendon autograft reconstruction on neuromuscular performance, by Edward M. Wojtys and Laura J. Huston, in the Proprioception and Neuromuscular Considerations Subsection.
Current Trends in Anterior Cruciate Ligament Reconstruction; Part 2: Operative Procedures and Clinical Correlations, Freddie Fu et al.; The American Journal of Sports Medicine, Baltimore; Jan/Feb 2000, Vol 28/1, p. 124-130. Comments: This absolutely superb article provides a comprehensive overview of the anatomy, physiology, and kinematics/biomechanics of the natural and reconstructed ACLs. (This article is the second of a two-part set.)
Current Trends in Anterior Cruciate Ligament Reconstruction; Part 1: Biology and Biomechanics of Reconstruction, Freddie Fu et al.; The American Journal of Sports Medicine, Baltimore; Nov/Dec 1999, Vol 27/6, p. 821-830. Comments: This absolutely superb article provides a comprehensive overview of the anatomy, physiology, and kinematics/biomechanics of the natural and reconstructed ACLs. (This article is the first of a two-part set.)
For penetrating insight into the use of patellar-tendon autografting in the context of degenerate (osteoarthritic) or otherwise articular-cartilage-compromised knees, please see (in addition to the article A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction, by Noyes and Barber-Westin, referred to immediately below), Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage, also by Noyes and Barber-Westin, as well as Anterior cruciate ligament (ACL)-deficient knee with degenerative arthrosis: treatment with an isolated autogenous patellar tendon ACL reconstruction, by Shelbourne and Stube, in the ACL Reconstruction in the Arthritic Knee Subsection. Meanwhile, penetrating insight into the use of patellar-tendon allografting (instead of autografting) for arthritic ACL-deficient knees can be found in Arthroscopic-Assisted Allograft Anterior Cruciate Ligament Reconstruction in Patients With Symptomatic Arthrosis, again by Noyes and Barber-Westin.
A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction, Frank R. Noyes et al.; American Journal of Sports Medicine, Baltimore; July/August 1997, Vol 25/4, p. 460-471. Comments: This superbly done and profoundly insightful study demonstrates the viability of using the patellar-tendon autograft for ACL reconstruction, for both acute knee injuries and chronic ones. For knees with chronic ACL tears, the rehabilitation was more difficult, but the results were still well worthwhile. Note that any knee that is allowed to remain ACL-deficient for extended periods of time will accumulate additional pernicious damage in the form of meniscal erosion and accelerated wear of components, and also gradual stretching-out of secondary restraints; these concerns are present even if the ACL-deficient knee does not actually give way after the initial injury. Clearly, prompt reconstruction of complete or near-complete ACL tears (and in any case, ACL tears of sufficient severity to render the knee unstable) is always best. The success rate for patellar-tendon autografting, for first-time ACL reconstruction, is about 95%; in this study, it was 93% overall (i.e. including both the knees with acute and chronic ACL tearing). Patellar-tendon autografting remains the gold standard today, especially given its unique advantage of secure healing due to bone plugs at both ends. The authors additionally note the importance of meniscal repair; even tears to the central avascular zone of the meniscus are amenable to repair. The best method for meniscal repair involves meticulous suturing. Although this is time-consuming for the surgeon to perform, it brings long-term benefits for the patient. As for articular-cartilage condition, the authors note that articular-cartilage damage was observed in 42% of the patients in the chronic subgroup and in 33% of the patients in the acute subgroup, at time of ACL reconstruction. This is not surprising, because ACL tears are very often accompanied by bone-bruising (in addition to meniscal tearing); articular-cartilage damage tends to worsen the longer an ACL-deficient knee is left unstable. Fortunately, even in unstable knees harbouring considering articular-cartilage abnormalities, ACL reconstruction is still well worthwhile.
For insight into the treatment of combined ACL-MCL tearing injuries, please see Anterior cruciate ligament-medial collateral ligament injury: Nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction: A preliminary report, by Shelbourne and Porter, and also The Treatment of Acute Combined Ruptures of the Anterior Cruciate and Medial Ligaments of the Knee, by Noyes and Barber-Westin, in the Injuries Involving the MCL and Treatment Thereof Subsection.
Note: A deep archive of articles and abstracts from Cincinnati Sports Medicine (CSM) Centre, including many landmark studies in the realm of knee biomechanics and trend-setting articles in the fields of ACL reconstruction and meniscal repair, can be found in directly on the CSM Publications Website. The article-publication dates range from 1980 to present. (Note that some of the newer articles are also present directly in this Knee Library.) On the CSM site, full-text articles are given as scanned-to-PDF files. Microsoft Windows users should, due to file-size considerations, download these by right-clicking and choosing "Save Target As". (The files must then be viewed using Adobe/Xerox Acrobat Reader, which is freely available for all computing platforms here.) Some articles on the CSM site are available only as abstracts; however, full-text printed copies may be obtained by contacting Sue Barber-Westin at sbwestin(at)csmref.org.
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