Knee stability following ACL reconstruction
Author: David P Johnson Date: 12/15/2009
"New Research confirms: "Postoperative knee instability was less common after
ACL reconstruction with patellar tendon autograft than with hamstring tendon
Mr. David Johnson MD, Consultant Orthopaedic Surgeon, The Bristol Knee Clinic:
Anterior Cruciate Ligament reconstruction has become more common over the last 15 years and successful restoration of knee stability is essential to allow a return to sports and avoid long term arthritic changes in the knee. The patellar tendon graft has always been the international gold standard to which other techniques such as the hamstring tendons have been compared. However in the UK the use of the hamstring graft has become popular with some surgeons despite the lack of evidence and outcomes studies to support use of hamstring tendons. Indeed all the other orthopaedic surgeons in the South West and in particular Bristol almost exclusively use the hamstring technique. For many years I have been the only surgeon advocating the long term success of the patellar tendon technique.
A new international meta-analysis statistically reviewed a collection of the best international prospective comparative trials of the use of patellar tendon grafts and hamstring tendons for ACL ligament reconstruction. The results were that the hamstring tendon technique would fail in as many as 36% of cases. The unequivocal conclusions were: "Postoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft." Dec 2009 AMJSpMed 37; 2009. 2470-8.
Mr. David Johnson MD Consultant Orthopaedic Surgeon; The Bristol Knee
www.Bristol-Knee-Clinic.co.uk Tel: 01179 706655
Am J Sp Med December 2009: AMJSpMed 37; 2009. 2470-8.
Current Concepts: Clinical Sports Medicine Update
Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the
Anterior Cruciate Ligament A Meta-Analysis Based on Individual Patient Data
Background: The best means of ensuring knee stability after anterior cruciate
ligament (ACL) reconstruction remains a core debate in sports medicine.
Study Design: Meta-analysis of individual patient data.
Methods: Pooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixed-effects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial.
Results: Anterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24–0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female (P = .003) and younger patients (P = .017).
Conclusion: Postoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft.
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