Arthroscopy: The Journal of Arthroscopic & Related Surgery
Evidence-Based Medicine Series Systematic ReviewTreatment of Anterior Cruciate Ligament Injuries With Special Reference to Graft Type and Surgical Technique: An Assessment of Randomized Controlled Trials
Section snippets
Research questions
- 1
How does the selection of graft type in ACL reconstruction affect the clinical outcome?
- 2
How do different surgical techniques such as tunnel placement and single- versus double-bundle reconstruction affect the clinical outcome?
- 3
What is the quality of RCTs in terms of study design and bias occurrence?
Literature search
The literature search took place between April 2007 and March 2009. We used the MEDLINE database, which was accessed online through PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez/). We started with a
Results
The studies are divided according to different outcome measures and assessment tools; special focus was directed toward differences over time and at studies with midterm to long-term follow-up.
Patellar Tendon Versus HT (26 Articles)
The BPTB graft has been the gold standard for ACL reconstruction over the last 3 decades. The HT graft, however, has been gaining ground during the last decade because of several factors, but are these factors based on solid ground?
ST Tendon Versus ST/G Tendon (2 Articles)
The doubled ST/G tendon graft and the quadrupled ST tendon graft both have several advantages as compared with the BPTB graft: greater mechanical strength, greater initial fixation strength that allows accelerated rehabilitation, and a larger surface area that could be advantageous in promoting revascularization.29
Patellar Tendon Versus Bone–Hamstring Tendon–Bone Graft (1 Article)
Several studies have used different fixation methods for patellar tendon and HT grafts. This can give misleading results if the assessment only considers graft type. Because of the difference in harvested material, in which the patellar tendon graft has “bone plugs,” it is difficult to use the same fixation method. If the surgeon were to use bone plugs for the hamstring graft, then the same fixation method could be used for both graft types, and a more realistic comparison could be made.
In 2006
Ipsilateral Versus Contralateral HT Harvest (1 Article)
In 1995 Yasuda et al.32 published a study in which 70 patients were divided into 2 groups: 1 group with ipsilateral 4-strand ST/G graft harvest and 1 group with contralateral 4-strand ST/G graft harvest. The mean Cincinnati score decreased at 2 weeks after surgery and then returned to the same level as before surgery by 3 months. No differences were found between the 2 groups in terms of AP laxity, ROM, or isometric quadriceps strength. However, isometric hamstring muscle strength in the knees
AP Laxity
In summary, there are 8 studies in this category: Six studies found no difference between the single-bundle graft and double-bundle graft in terms of AP laxity.10, 33, 34, 35, 36, 37 Two studies found that the double-bundle graft yielded less AP laxity.38, 39
In 2004 Adachi et al.34 published their study in which they compared single-bundle 4-strand ST/G graft with double-bundle 2-strand ST/G graft. During the 2-year follow-up, no difference was found in terms of side-to-side AP laxity. The
Graft type
The difference in laxity is a topic of great concern when one is confronted with graft choice in ACL reconstruction. Even though the structural strength of the quadrupled HT graft is superior to that of the BPTB graft and the soft tissue-to-bone interface of the HT graft is healed only weeks after the BPTB graft, many believe that the HT graft is inferior to the BPTB graft in terms of residual laxity and increased laxity over time. Regardless of graft type, ACL reconstruction reduced
Graft Type
- •
There are no differences between the BPTB graft and the HT grafts in terms of laxity, clinical outcome, time to return to sports, patellofemoral crepitations, 1-leg hop test, ROM, thigh muscle circumference, and anterior knee sensory deficit.
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The BPTB graft produces more AKP and kneeling pain than the HT graft, but the difference disappears with time.
- •
Harvest site affects muscle strength initially but not over time.
- •
There is a possible correlation between the development of osteoarthritis and the
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The authors report no conflict of interest.