A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. A prospective randomized comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction. A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up. Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Clinical evaluation of arthroscopically assisted anterior cruciate ligament reconstruction: patellar tendon versus gracilis and semitendinosus autograft. Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial.
In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial. Patellar and hamstring tendon autografts are the most frequently used graft types for anterior cruciate ligament reconstruction, but few direct comparisons of outcomes have been published.
                There is no difference in outcome between the two types of reconstruction.
                Prospective randomized clinical trial.
                After isolated anterior cruciate ligament rupture, 65 patients were randomized to receive either a patellar tendon or a four-strand hamstring tendon graft reconstruction, and results were reviewed at 4, 8, 12, 24, and 36 months.
                Pain on kneeling was more common and extension deficits were greater in the patellar tendon group. There were greater quadriceps peak torque deficits in the patellar tendon group at 4 and 8 months but not thereafter. In the hamstring tendon group, active flexion deficits were greater from 8 to 24 months, and KT-1000 arthrometer side-to-side differences in anterior knee laxity at 134 N were greater. Cincinnati knee scores, International Knee Documentation Committee ratings, and rates of return to preinjury activity levels were not significantly different between the two groups.
                Both grafts resulted in satisfactory functional outcomes but with increased morbidity in the patellar tendon group and increased knee laxity and radiographic femoral tunnel widening in the hamstring tendon group. The choice of graft for anterior cruciate ligament reconstruction is a matter of debate, with patellar and hamstring tendons being the two most popular autologous graft options. The objective of this study was to determine in a prospective, randomized clinical trial whether two grafts (bone-patellar tendon-bone or doubled hamstring tendons) fixed with modern devices affect the two-year minimum clinical and radiographic outcomes of anterior cruciate ligament reconstruction.
                One hundred and twenty patients with a chronic unilateral rupture of the anterior cruciate ligament underwent arthroscopically assisted reconstruction with use of either autologous bone-patellar tendon-bone or doubled hamstring tendon grafts, in a strictly alternating manner. Both groups were comparable with regard to demographic data, preoperative activity level, mechanism of injury, interval between the injury and the operation, and the amount of knee laxity present preoperatively. The same well-proven surgical technique and aggressive controlled rehabilitation was used. An independent observer, who was blinded with regard to the involved leg and the type of graft, performed the outcome assessment with use of a visual analog scale, the new International Knee Documentation Committee form, the Knee Injury and Osteoarthritis Outcome Score, the Functional Knee Score for Anterior Knee Pain, and an arthrometric and an isokinetic dynamometric evaluation. Radiographs were also made.
                At the two-year follow-up evaluation, no differences were found in terms of the visual analog score, the Knee Injury and Osteoarthritis Outcome Score, the new International Knee Documentation Committee subjective and objective evaluation scores, the KT-1000 side-to-side laxity measurements, the Functional Knee Score for Anterior Knee Pain, muscle strength recovery, or return to sports activities. In the bone-patellar tendon-bone group, we found a higher prevalence of postoperative kneeling discomfort (p < 0.01) and an increased area of decreased skin sensitivity (p < 0.001). In the hamstring tendon group, we recorded a higher prevalence of femoral tunnel widening (p < 0.01). In this group, a correlation was also found between medial meniscectomy and an increased prevalence of pivot-shift glide (p = 0.035).
                We believe that, with use of accurate and proven surgical and rehabilitation techniques, both grafts are an equivalent option for anterior cruciate ligament reconstruction. The aim of this study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using central-third, bone-patellar tendon-bone (BPTB group), 3-strand semitendinosus (ST group), or 4-strand semitendinosus/gracilis (ST/G group) autografts.
                Prospective randomized trial.
                A randomized series of 134 patients, all with unilateral ACL rupture was included in the study. In all 3 groups, interference screw fixation of the graft was used at both ends and 125 of 134 (93%) of the patients returned for the follow-up examination after 26 months (range, 20 to 43 months). The preoperative assessments in all 3 groups were similar in terms of gender, Tegner activity level, Lysholm score, KT-1000 measurements, 1-leg hop test, and the knee-walking test.
                At follow-up, the knee-walking test was significantly worse in the BPTB group than in the ST group (P = .0004) and ST/G group (P < .0001). Furthermore, the knee-walking test was significantly worse at follow-up than preoperatively in the BPTB group (P < .0001). The corresponding findings were not made in the other 2 groups. A significant reduction in knee laxity and an increase in activity level compared with the preoperative assessments were found in all 3 groups, without any significant differences between the groups.
                Two years after ACL reconstruction, the use of ST and ST/G autografts rendered significantly less discomfort during the knee-walking test than the use of BPTB autografts. However, in terms of functional outcome and knee laxity, the groups displayed no significant differences.
                Level I. Debate exists regarding the optimal graft for anterior cruciate ligament reconstruction. Few studies have compared the differences in outcome after reconstruction using similar fixation methods.
                Similar outcomes will be seen after anterior cruciate ligament reconstruction with bone-patellar tendon-bone or quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws.
                Randomized controlled trial; Level of evidence, 1.
                Ninety-nine patients were prospectively randomized to bone-patellar tendon-bone (46 patients) or quadruple-strand semitendinosus/gracilis (53 patients) reconstruction groups. The bone-patellar tendon-bone group had slightly lower preinjury Tegner scores (6.7 vs 7.1, P = .03); otherwise, the groups were similar. All surgeries were performed by a single surgeon using an endoscopic technique with bioabsorbable interference screw fixation. Patients were evaluated at 3, 6, 12, and 24 months.
                Forty-six bone-patellar tendon-bone and 50 quadruple-strand semitendinosus/gracilis patients were available at 24 months (97%). No differences in International Knee Documentation Committee grade, Lysholm score, Tegner activity level, range of motion, single-legged hop test, KT-1000 arthrometer manual maximum difference, Short Form-36, or patient knee rating were found. The bone-patellar tendon-bone group had better flexion strength in the operated leg than in the nonoperated leg (102% vs 90%, P = .0001), fewer patients complaining of difficulty jumping (3% vs 17%, P = .03), and a greater number of patients returning to preinjury Tegner level (51% vs 26%, P = .01). The quadruple-strand semitendinosus/gracilis group had better extension strength in the operated leg than in the nonoperated leg (92% vs 85%, P = .04), fewer patients with sensory deficits (14% vs 83%, P = .0001), and fewer patients with difficulty kneeling (6% vs 20%, P = .04). Both groups showed significant improvement in KT-1000 arthrometer manual maximum difference, Lysholm score, Tegner activity level, International Knee Documentation Committee grade, and patient knee rating score.
                Good outcomes were seen in both the bone-patellar tendon-bone and quadruple-strand semitendinosus/gracilis groups. Subtle differences were noted between the groups, which may help guide optimal graft choice. There are still controversies about graft selection for primary anterior cruciate ligament reconstruction. Prospective randomized long-term studies are needed to determine the differences between the materials.
                Five years after anterior cruciate ligament reconstruction, there is a difference between hamstring and patellar tendon grafts in development of degenerative knee joint disease.
                Randomized controlled trial; Level of evidence, 1.
                From June 1999 to March 2000, 64 patients were included in this prospective study. A single surgeon performed primary arthroscopically assisted anterior cruciate ligament reconstruction in an alternating sequence. In 32 patients, anterior cruciate ligament reconstruction was performed with hamstring tendon autograft, whereas in the other 32 patients, anterior cruciate ligament reconstruction was performed with patellar tendon autograft.
                At the 5-year follow-up, no statistically significant differences were seen with respect to the Lysholm score, clinical and KT-2000 arthrometer laxity testing, anterior knee pain, single-legged hop test, or International Knee Documentation Committee classification results; 23 patients (82%) in the hamstring tendon group and 23 patients (88%) in the patellar tendon group returned to their preinjury activity levels. Graft rupture occurred in 2 patients from the hamstring tendon group (7%) and in 2 patients from the patellar tendon group (8%). Grade B abnormal radiographic findings were seen in 50% (13/26) of patients in the patellar tendon group and in 17% (5/28) of patients in the hamstring tendon group (P = .012).
                Both hamstring and patellar tendon grafts provided good subjective outcomes and objective stability at 5 years. No significant differences in the rate of graft failure were identified. Patients with patellar tendon grafts had a greater prevalence of osteoarthritis at 5 years after surgery. A prospective randomized study was performed to determine the differences in results between three methods of anterior cruciate ligament reconstruction: autogenous bone-patellar tendon-bone graft (group 1), semitendinosus and gracilis tendon graft reconstruction combined with an extraarticular procedure (group 2), and semitendinosus and gracilis tendon graft reconstruction alone (group 3). Preoperatively, there were no significant differences between groups. At a mean of 35.4 +/- 11.6 months postoperatively, 102 patients returned for evaluation. International Knee Documentation Committee knee evaluation revealed no significant differences in symptoms, function, return to pre-injury activity, harvest site abnormalities, or limitation of motion between groups 1 and 3. Patients in group 2 had a higher incidence of patellofemoral crepitation and loss of motion than did patients in group 3. The mean manual maximum KT-1000 arthrometer side-to-side difference was 2.1 +/- 2.0 mm in group 1, which was statistically significantly better than the difference in group 3 (3.1 +/- 2.3 mm). Final knee rating showed that 34 of 35 patients in group 1, 23 of 34 patients in group 2, and 26 of 33 patients in group 3 had a normal or nearly normal overall knee rating. Anterior cruciate ligament reconstruction with a semitendinosus and gracilis or a patellar tendon autograft may yield similar subjective results; however, the patellar tendon autograft may provide better objective stability in the long term. In addition, there appears to be no benefit to combining an intraarticular anterior cruciate ligament reconstruction with an extraarticular procedure. To evaluate the clinical results of anterior cruciate ligament (ACL) reconstruction in patients with ACL-deficient knee in 2 similar groups of patients.
                A prospective randomized comparison of patellar tendon (PT) versus semitendinosus and gracilis tendon (STG) autografts for ACL reconstruction.
                Between 1994 and 1996, 85 consecutive male patients with chronic ACL-deficient knees underwent arthroscopically assisted reconstruction with either autologous PT or double-loop STG (4-strand) graft. PT grafts were used in patients with even-numbered birth dates and STG grafts for those with odd-numbered birth dates. Preoperatively, no significant differences between the 2 groups were noted with respect to age, level of activity, and degree of laxity (chi-square analysis). A standardized rehabilitation program was used for both groups postoperatively that included immediate active extension and early weight bearing and gradual flexion. Return to sports was permitted 8 months postoperatively. Assessment of the patients was carried out using a questionnaire, clinical assessment, Lysholm knee scores, the International Knee Documentation Committee scale, and radiological examination.
                At a mean follow-up of 81 months, there was no significant difference between the 2 groups with respect to subjective complaints (recurrent giving way, functional level) or objective laxity evaluation, including KT-1000 measurement or return to sports. Loss of extension of < or =5 degrees was greater in the PT group (12 patients, 30 %) than in the STG group (8 patients, 17 %). There was loss of flexion of < or =15 degrees in 5 patients (12 %) in the PT group and 1 patient (2.2 %) in the STG group. Anterior knee pain was recorded in 10 patients (24 %) in the PT group and 3 patients (5 %) in the STG group. The Lysholm knee score was 91.6 and 92.7 for the PT and STG groups, respectively, and the Tegner activity score decreased from 8.9 preoperatively for both groups to 7.9 for the PT group and 7.8 for the STG group.
                In this study, the 2 groups had comparable results in terms of patient satisfaction, activity level, and knee function. Our study showed that patellofemoral problems and loss of knee motion are more frequent in patients with PT grafts than in those with STG grafts.
                Level I, Randomized Controlled Trial. Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published.
                The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction.
                Randomized controlled clinical trial; Level of evidence, 1.
                Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation.
                All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more "normal knees" in the DB group than in the SB group (P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08).
                In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed.
There is insufficient evidence to draw conclusions on differences between the two grafts for long-term functional outcome. While PT reconstructions are more likely to result in statically stable knees, they are also associated with more anterior knee problems.