Question: In patients with anterior cruciate ligament
(ACL) tears, how do the results of three surgical methods of reconstruction
compare in terms of function, symptom relief, and return to preinjury
activity?
Design: Randomized (allocation concealment unclear),
blinded (data analyst), controlled trial with a mean duration of
follow-up of 35 months.
Setting: An orthopaedic clinic in Nashville, Tennessee,
USA.
Patients: 105 patients (mean age, 22 years; 65% men)
who required anterior cruciate ligament reconstruction. Inclusion
criteria were no previous knee surgery other than meniscectomy,
a normal contralateral knee, no evidence of osteoarthritis in either
knee, no history of patellofemoral pain or substantial patellofemoral crepitation,
age of <50 years, and absence of meaningful injury to other
ligamentous structures. 102 patients (97%) completed the follow-up.
Intervention: Patients were allocated to intra-articular
anterior cruciate ligament reconstruction with use of an autogenous
bone-patellar tendon-bone graft (group 1; n = 35), a semitendinosus
and gracilis tendon graft combined with a Losee extra-articular
iliotibial band tenodesis (group 2; n = 35), or a semitendinosus
and gracilis tendon graft alone (group 3; n = 35)
Main outcome measures: Range of motion, stability
(measured objectively with use of a KT-1000 arthrometer), patellofemoral
crepitation, muscle strength (measured with use of a Cybex-II dynamometer),
and results of the International Knee Documentation Committee (IKDC)
knee evaluation.
Main results: The 3 treatment groups did not differ
with regard to range of motion, patellofemoral crepitation, or muscle
strength. The groups also did not differ with regard to their return
to their preinjury activity level; 83%, 74%, and
88% of patients in group 1, group 2, and group 3, respectively,
could partake in IKDC level-I activities (very strenuous) at the
time of final follow-up. Patients treated with the autogenous bone-patellar
tendon-bone graft (group 1) had better stability than did patients treated
with the semitendinosus and gracilis tendon graft alone (group 3);
the mean maximum side-to-side difference was 2.1 vs 3.1 mm for groups
1 and 3, respectively (P < 0.05). The groups did not differ
with regard to the IKDC subjective assessment or symptoms, but more patients
in group 1 had a final IKDC rating of normal or nearly normal (P = 0.02)
than did those in either of the other 2 treatment groups (table).
Conclusions: In patients with anterior cruciate ligament
(ACL) tears, 3 surgical methods had comparable results with regard
to decreasing symptoms, improving function, and allowing a full
return to preinjury activity. Patients who underwent anterior cruciate
ligament reconstruction with use of an autogenous bone-patellar
tendon-bone graft had better stability and more normal knee ratings than
did those who received a semitendinosus and gracilis tendon graft.
The addition of an extra-articular procedure in anterior cruciate
ligament reconstruction was not of benefit.