ACL reconstruction: no difference between hamstring and patellar tendon grafts
Anterior Cruciate Ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: A systematic literature review of outcome from surgeryKnee. 2005 Jan;12(1):41-50
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This systematic review identified 13 randomized controlled trials, comparing patellar tendon (PT) grafts with combined semitendinosis and gracilis tendon (hamstring) (HT) grafts in ACL reconstruction. From these trials, a total of 1145 patients were included. Overall, the studies reported that there was no significant difference between the two groups for recovery of sporting ability, pain, knee stability, function, muscle strength, range of motion and complication rates. Both grafts led to similar improvement in patients with ACL injuries.
Were the search methods used to find evidence (original research) on the primary question or questions stated?
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Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
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The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Anterior cruciate ligament (ACL) injuries are very common and can lead to reduced function of the knee, meniscal lesions, and early joint degeneration. The most commonly used surgical treatment is arthroscopically assisted ACL reconstruction, using either central third of the patellar tendon (PT) grafts or combined semitendinosis and gracilis tendon (hamstring) (HT) grafts. However, there is a lack of consensus regarding the best tissue graft, and there are few randomized controlled trials directly comparing the two most popular options. The purpose of this review was, therefore, to identify randomized trials that examined the PT and HT grafts and to determine if there was an advantage of one over the other in patients undergoing ACL reconstruction.
What was the principal research question?
Is there a difference between PT and HT grafts in terms of function, recovery of sporting ability, pain, knee stability, muscle strength, range of motion, reoperation rate and complications, in patients undergoing ACL reconstruction?
What were the important findings?
- Out of 5 studies, all reported that there was no difference between the HT and PT groups for Tegner activity scores, evaluating the ability to return to the pre-operative level of sporting ability.
- 8 studies reported pain outcomes: 3 studies reported no difference between the two groups for pain; 2 studies stated that the two groups did not differ in patellofemoral pain at 2 years; one study reported that fewer patients with a hamstring tendon graft felt kneeling pain and that the PT group experienced less anterior knee pain at 12 months; 2 studies indicated that the PT group experienced more patellofemoral pain than the HT group
- Muscle strength (peak extension and flexion, and isokinetic quadriceps muscle torque) did not differ significantly between the two groups at the last follow up, according to 8 studies; one study indicated that the HT group had a significantly weaker endurance flexion at 240 deg/s than the PT group at all follow up times
- 4 studies found that there was greater knee stability (measured with the KT-1000 arthrometer) in the PT group than in the HT group, whereas another 4 studies found no difference between the two groups; the two groups also did not differ significantly when evaluated using the Stryker test, the KT-2000 arthrometer, the CA-4000, and the pivot shift test
- A greater limitation of extension was found in the PT group than in the HT group, according to 3 studies; the rest of the studies found no difference between the two groups
- From 5 studies, most patients from both groups had normal or nearly normal knees at 2 years, according to IKDC scores
- Re-operation was needed in significantly more HT patients (54) than PT patients (20)
- The number of complications in the PT group (7) did not differ from the HT group (7)
What should I remember most?
There were advantages and disadvantages for both grafts demonstrated in some of the included studies. For example, results from some studies suggested that PT grafts lead to greater knee stability and that the HT graft allowed for less limitation of extension and may have reduced the prevalence of anterior knee pain. However, overall results suggested that there was no significant difference between the two. Both grafts appeared to be effective for patients requiring ACL reconstruction.
How will this affect the care of my patients?
Overall results indicate that there is little difference between PT and HT grafts with respect to activity scores, pain, muscle strength, knee stability, function, and complication rate. Further randomized controlled trials with larger sample sizes are needed to make further conclusions about the two types of grafts.
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