|Year : 2013 | Volume
| Issue : 3 | Page : 267-273
A comparison of hamstring autograft versus bone patella tendon bone autograft for reconstruction of anterior cruciate ligament: A prospective study of 30 cases
Sanjay Deo, Ramprasad Rallapalli, Samar K Biswas, Anil K Salgia
Department of Orthopaedics, Dr. D.Y. Patil Medical College, Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||5-Jul-2013|
202/B, Bhairavi Apt ICS Colony, Bhoslenagar, Shivajinagar, Pune
Source of Support: None, Conflict of Interest: None
Background and Aim: Anterior cruciate ligament (ACL) deficient knee usually present with instability of the knee, in our study we are comparing the results of ACL reconstruction using bone-patellar-bone and quadrupled stranded hamstring tendon grafts. Materials and Methods: Thirty patients presenting with chief complaints of the knee instability were diagnosed clinically by Lachman test, anterior drawer test, pivot shift test and confirmed by diagnostic arthroscopy or MRI to have ACL tear. ACL tears that are more than 6 weeks old are included. Fifteen patients were treated with ACL reconstruction using autologous ipsilateral hamstringtendon and 15 patients were treated with bone patellar tendon bone graft through arthroscopy assisted technique. All patients were reviewed and analyzed at the end of 1 year post-operatively. Assessment includes pre-operative, intra-operative findings and post-operative subjective assessment scores and examination findings, pre- and post-operatively the Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) evaluation system were used as scoring systems. Results: Comparisons of results within the same groups showed statistically significant improvement as assessed by IKDC, Tegners and Lysholm operative scores. There was also significant correlation between manual Lachman test and stress laxometry findings. There was no statistically significant difference between scores of two groups (hamstring and bone patella tendon). Conclusions: Arthroscopic ACL reconstruction by either quadrupled hamstring tendon graft or bone patellar tendon graft gives equally satisfactory results.
Keywords: Anterior cruciate deficient knee, bone patella bone graft, hamstring quadrupled graft
|How to cite this article:|
Deo S, Rallapalli R, Biswas SK, Salgia AK. A comparison of hamstring autograft versus bone patella tendon bone autograft for reconstruction of anterior cruciate ligament: A prospective study of 30 cases. Med J DY Patil Univ 2013;6:267-73
|How to cite this URL:|
Deo S, Rallapalli R, Biswas SK, Salgia AK. A comparison of hamstring autograft versus bone patella tendon bone autograft for reconstruction of anterior cruciate ligament: A prospective study of 30 cases. Med J DY Patil Univ [serial online] 2013 [cited 2020 Sep 18];6:267-73. Available from: http://www.mjdrdypu.org/text.asp?2013/6/3/267/114657
| Introduction|| |
Anterior cruciate ligament (ACL) tear is the most serious ligament injury to the knee joint. ACL injury is quite common among the young active population especially in athletes and contact sports. With high velocity accidents on road ACL injury has become common. The ACL is the primary stabilizer against anterior translation of the tibia on the femur and is important in counteracting rotation and valgus stress. ACL deficiency leads to knee instability. This results in recurrent injuries and increased risk of intra-articular damage, especially the meniscus. The goals of the ACL reconstruction are to restore stability to the knee; allow the patient to return to normal activities, including sports; and to delay the onset of osteoarthritis with associated recurrent injuries to the articular cartilage and loss of meniscal functions.  Since last 10 years arthroscopically assisted techniques have been an accepted method of reconstructing the ACL. 
In our study, we selected our patients into two groups, depending on the type of graft used for reconstruction, according to their order of attendance at our institute and subsequently followed-up for 1 year. Our aim of the study was to compare both (bone-patella-bone with hamstring semitendinosus (HS) auto graft) groups in terms of subjective and objective outcome.
| Materials and Methods|| |
This was a prospective study of thirty patients presenting to orthopedics department of a teaching medical college in Pune, India from August 2009 to August 2011 They were assessed by Lachman test, anterior drawer test, pivot shift test with MRI evidence of ACL tear. These patients were treated with ACL reconstruction using either autologous ipsilateral HS or bone patellar tendon bone (BPTB) graft arthroscopically. There were 15 patients in the BPTB group and 15 in the hamstring group. The patients were allocated in the two groups alternatively. These procedures were performed by two surgeons equally proficient in both methods of reconstruction mentioned in this study. Post-operative evaluations including ligament laxity tests were done by single observer and documented.
The patients included in our study were of the age group 18-40 years, with ACL tear more than 6 weeks duration, with no history of previous surgery or previous cruciate ligament damage in the affected knee. Patients with associated medial collateral or lateral collateral ligament tear grade 1 or 2 with meniscal injury.
Those patients with posterior cruciate ligament laxity and with evidence of osteoarthritis on plain radiograph and with medial/lateral collateral ligament tear grade 3/4 were excluded.
All the patients were followed-up for a period of 1 year.
In BPTB the graft was harvested and prepared as shown in [Figure 1]a-d. The graft was inserted through the drill hole assisted arthroscopically. Patella bone graft was put on the femoral side and the tibial bone graft on the tibial side. The graft was fixed with interferential screws.
|Figure 1: Preparation of bone patella bone graft (a) separating central third of patellar tendon (b) bone patellar tendon bone graft separated (c) graft double bundled and ethibond sutures passed (d) graft passed through sizers|
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In HS graft the graft was harvested, quadrupled and pre-tensioned as shown in [Figure 2]a-d. Then graft was inserted through the drill hole assisted arthroscopically. The fixation was done with endobutton.
|Figure 2: Preparation of semi-tendinous graft (a) 3 cm incision on medial side of tibial tuberosity (b) measuring tendon (c) tensioning the graft (d) introduction of graft|
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Clinical evaluation was done by Lachman test, anterior drawer test, pivot shift test, International Knee Documentation Committee (IKDC) subjective evaluation form  Tegners activity level scale  and Lysholm scoring scale. 
- IKDC subjective assessment score 
- Tegners' score 
- Lysholm scores  and
- IKDC objective evaluation  which includes manual stress laxometry radiographs and post-operative complications.
After the removal of drain on day 2, patient was encouraged to do partial weight bearing with long knee brace. Post-operative dressings were done on day 2, 5, 8 and sutures were removed on day 12. Broad spectrum intravenous (I.V) antibiotics were given for 5 days. Robert Jones compression bandage was applied for every patient. Patient was asked to do knee bending up to 15° after day 3 to full range gradually.
Goals of rehabilitation were pain and swelling control, maintaining range of motion, protection of ACL graft, building hamstring and quadriceps muscles and regaining near normal strength and return to pre-injury level of activity.
- Statistical analysis was done using SPSS software (Statistical Package for Social Science, V 10.5 package).
- Comparison of variables between groups was carried out by the Mann-Whitney U test.
- A P value of <0.05 was considered statistically significant.
| Results|| |
Most of the patients present in the range of 21-35 years. The average age was 28.3 years
Out of 30 patients operated 4 were women and remaining 26 were men.
Right side ACL deficiency was seen in eighteen (60%) patients and twelve patients (40%) had left side involvement.
Mechanism of Injury
Out of 30 patients, 13 had valgus external rotation, nine had varus internal rotation, six had extension internal rotation and two had acceleration deceleration type of injury in extension.
Pre-operative IKDC Scores
IKDC score ranged from 13.8 to 65.5 with mean 47.98 and median 51.1.
Pre-operative Range of Motion
Range of motion was measured with Goniometer and is shown in [Table 1].
Pre-operative Tegners Scores
Range of scores was 2-9 with mean value 4.32 and median value four suggestive of average activity levels of moderately heavy labor (SD = 2.54).
Pre-operative Lysholm Scores
Range was 15-100 with mean value of 52.166 and median value of 52.5 (SD = 20.6).
Functions Before and After Surgery
Function before injury recorded on visual analog scale all patients scored 10/10. Function after injury recorded on visual analog scale range 2-9 is with mean value is 7.53 with median value of 7 (SD = 19.8).
Time from Injury to Surgical Intervention
Time period from injury to surgical intervention ranges between 2 months and 120 months with mean of 16.08 months and median of 11 months.
Status of Associated Lesions at the Time of Surgery
This is shown in [Table 2].
Post-operative Subjective Assessment
Post-operative Tegners' Activity Level Scores
- Patients who had ACL with BPTB graft had mean score of 68.7 with range 52-81.6 (SD = 22.56)
- Patients who had ACL reconstruction with qudrapled hamstring tendon had mean score of 64.7 with range 30-87 (SD = 23.66).
Post-operative Lysholm Scores
- Mean post-operative score for BPTB graft patients was 5.44 and with median value of 5 and ranges 5-8 (SD = 20.8)
- Mean post-operative score for Hamstring graft patients was 6.08 and with median value of 6 and ranges 4-8 (SD = 19.8).
Post-operative Activities of Daily Living
- Mean post-operative score in BPTB graft group is 76.33 with median value 86 and range 25-99 (SD = 16.6)
- Mean post-operative score in HS graft group is 81.23 with median value 93 and range 25-100 (SD = 26.6).
Post-operative Range of Motion
- Mean post-operative score in BPTB graft group is 8.7 with median value 9 and range 5-10.
- Mean post-operative score in HS graft group is 9 with median value 9 and range 6-10.
Out of 30 patients one had fixed flexion deformity of knee and active range of motion of 0-110 in two patients and 0-120 in four patients and 0-140 in 24 patients [Table 3].
IKDC Effusion Grading
Out of thirty patients 21 scored grade A, 8 scored grade B and 1 scored grade C in IKDC objective assessment for knee effusion. BPTB graft group scored 11 A and 4 B. Hamstring graft group scored 10 A, 4 B and 1 C [Table 4].
The IKDC grading of ligament laxity are shown in [Table 5].
|Table 5: International knee documentation committee grading of ligament laxity|
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Harvest Site Pathology
Overall IKDC grades scored for harvest site pathology is shown in [Table 6].
|Table 6: International knee documentation committee grading of harvest site pathology|
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Overall grades are 13 A, 16 B and 1 C. BPTB graft group 6 A, 8 B and 1 C. Hamstring tendon graft group 7 A, 8 B [Table 7].
Radiographic Stress Laxometry
Out of thirty patients 17 patients achieved grade A and 13 patients achieved grade B. BPTB graft group grades achieved are 8 A and 7 B. In hamstring tendon graft group grades achieved are 9 A and 6 B [Table 8].
|Table 8: International knee documentation committee grading of radiographic stress laxometry|
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Overall complications noted were anterior knee pain in three patients, pain at terminal extension present in one patient, and early infection in one patient which subsided with antibiotics. In BPTB graft group anterior knee pain was seen in three patients and numbness lateral to patella seen in one patient. In Hamstring tendon graft group early infection was seen in one patient, pain at terminal 10° of extension was seen in one patient. One patient had flexion deformity of 15° because of the previous trauma he sustained in childhood; even his pre-operative motion was 15-100°.
For final end result evaluation all patients were reviewed at end of 1 year post-operatively. Results include pre-operative, intra-operative findings, post-operative Tegner's score, Lysholm's score, post-operative activities of daily living, and range of motion measured to the nearest 5° by a goniometer [Table 9].
| Discussion|| |
The goal of treatment of ACL deficient knee is to provide stable knee which prevents secondary injury to knee and potential early onset of osteoarthritis associated with ACL deficient knee. The most accepted method of surgical management at present for ACL deficient knee is ACL reconstruction using autologous BPTB or quadrupled hamstring tendon graft depending on operating surgeon's preference , with general tendency in North America towards BPTB graft while most of the Europe and some parts of Asia hamstring tendon graft is the preferred choice.
Thirty patients were included in the study. There were 15 patients in the BPTB group and 15 patients in the hamstring group. The dominant age group in our study is between 21 years and 30 years. There is significant difference between duration of injury and procedure done. Twenty six male patients are included to four female patients. Manual Lachman and anterior drawer's tests were used for stability testing. There was no difference in the number and the distribution of grading of instability in both groups.
In our study, overall post-operative results are satisfactory within each group in terms of IKDC subjective scores, Lysholm score, activities of daily living by visual analog scale and Tegner's activity levels scores, when compared to pre-operative scores. These short-term results are consistent with short-term study results reported by Eriksson et al.  This emphasizes the fact that both types of reconstruction are effective methods of restoring knee stability.
ACL reconstruction with BPTB graft was initially thought to be the gold standard method because of theoretical advantage of early graft integration in tunnels and mechanical strength when compared to two stranded hamstring tendon graft. Studies by Aglietti et al. 1997 and Beynnon et al. 2003 , reported better results for BPTB grafts in terms post-operative sagittal knee laxity studied by manual and instrumented Lachman tests.
Later on, with understanding and improvement of graft fixation such as by aperture fixation method and newer devices and equal tensioning of parallel strands of quadrupled hamstring tendon grafts, no significant differences were found between the two types of grafts in short-term studies.  In this study, there was slightly more laxity in hamstring tendon group, slightly lesser post-operative activity level in female patients and less anterior knee pain when compared to BPTB graft group. Results of recent short term study by Laxdal et al. 2006  also showed that no clinically significant differences could be found between two groups.
In a similar study, Corry, et al. found that the two grafts did not differ in terms of clinical stability, range of motion and general symptoms.  The hamstring tendon group also had a lower graft harvest site morbidity. 
In our study of comparison of post-operative subjective IKDC scores, Lysholm scores, activities of daily living scores and Tegner's activity levels scores between two groups no statistically significant difference could be found even in Tegner's activity levels scores. We have found that there is statistically significant correlation between laxity measurements by manual Lachman test and stress laxometry method suggesting this method could be used as an inexpensive alternative to instrumented Lachman tests such as K-1000 arthrometer. In this study no statistically significant difference could be found in laxity levels between two groups at 1 year follow-up. This study shows no statistically significant difference in single leg hop test between two groups. However, patients in either group failed to reach pre-injury activities of daily living by 1.2 over all points on visual analogue scale. Overall, 80% of the people in either group scored normal or near normal and 20% of people scored abnormal or severely abnormal IKDC grades.
Other results were anterior knee pain was noted in three patients with BPTB graft and none of our hamstring tendon graft group had anterior knee pain. Significant numbness lateral patella was another complication noted in one patient with BPTB graft and incidence of early infection in one patient, pain at terminal extension in one patient were seen in quadruple hamstring tendon graft patients.
Advantages of hamstring tendon graft over BPTB graft as given by authors of studies, which showed better results for hamstring tendon graft group are lesser future risk of osteoarthritis, paradoxical lesser laxity (possibly due to remodeling process) in the long term and lesser kneeling pain. 
In 2001, Yunes, et al. were the first to report a meta-analysis conducted from controlled trials of patellar tendon versus hamstring tendons for ACL reconstruction.  They found that the patellar tendon patients had a greater chance of attaining a statically stable knee and nearly a 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 post-operative activity levels and greater static stability than hamstring reconstruction. Similar results were reported by Biau et al. in 2006. 
In 2003, using the same and extended numbers of controlled trial, Freedman, et al. found that the rate of graft failure in the patellar tendon group was significantly lower and a significant higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group.  There was a higher rate of manipulation under anesthesia or lysis of adhesions and of 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 failure 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. 
A meta-analysis of various studies by Biau et al. 2006,  although, questioned methodological quality of studies reviewed, suggested no significant differences between two grafts and advised against BPTB graft in certain ethnic groups and occupations requiring kneeling activities and sports activities which involves jumping. However, another recent meta-analysis (also done by same authors  ) of individual patient data shows with newer surgical techniques no significant difference could be found between the two groups in terms of complications and considers BPTB graft continues to be an attractive option.
| Conclusions|| |
The patellar tendon group had comparatively more mechanical strength and more kneeling pain whereas the hamstring tendon group had lower graft harvest site morbidity as demonstrated by less kneeling pain at 1 year.
Arthroscopic ACL reconstruction by either quadrupled hamstring tendon graft or bone patellar tendon graft gives satisfactory results in short term follow up in terms of patient satisfaction, activities of daily living and return to near normal activity.
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[Table 8], [Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 9]