Abstract
Background: In this study, we analyzed the clinical outcomes at a
minimum of two years following reconstruction of the anterior cruciate
ligament with use of a four-strand hamstring tendon autograft in patients who
had presented with a symptomatic torn anterior cruciate ligament.
Methods: One hundred and twenty-two consecutive patients who had an
isolated, symptomatic anterior tibial subluxation associated with rupture of
the anterior cruciate ligament were treated with reconstruction of the
anterior cruciate ligament with a four-strand autologous
semitendinosus-gracilis tendon graft. One surgeon performed all of the
operations. Prior to surgery and at the follow-up examination, physical
findings and functional scores were recorded and knee radiographs were
analyzed. Following surgery, a six-month rehabilitation regimen was
implemented.
Results: Eighty-five patients (70%) were available for follow-up,
which included physical examination, scoring of function, KT-1000 arthrometric
testing, and radiographs, at a mean of twenty-eight months. Seventy-six (89%)
of the patients had negative Lachman and pivot shift tests. The mean Lysholm
score improved from 55 points preoperatively to 91 points at the time of
follow-up (p < 0.01). The mean Tegner score improved from 5 to 6 points (p
< 0.01). Sixty-five patients had <3 mm of knee translation on
arthrometric testing, but six patients with marked laxity were not tested.
Three patients (4%) had a positive pivot shift test but had no history of
additional trauma to the knee. Six patients (7%) had a traumatic rupture of
the graft, occurring at a mean of 10.7 months postoperatively. Assessment of
the follow-up radiographs demonstrated no evidence of progressive degenerative
change compared with the appearance on the preoperative radiographs. However,
tunnel expansion was noted in all patients. The tibial tunnel expanded a mean
of 17% (range, 0% to 32%), and the femoral tunnel expanded a mean of 29%
(range, 0% to 40%).
Conclusions: Reconstruction of the anterior cruciate ligament with
use of a four-strand hamstring tendon autograft eliminated anterior tibial
subluxation in 89% of patients who were examined at a minimum of two years
postoperatively. The overall rate of failure was 11%. The functional knee
scores were significantly increased at the time of follow-up, but these
results did not correlate with the results of knee arthrometric testing.
Level of Evidence: Therapeutic study, Level IV (case
series [no, or historical, control group]). See Instructions to Authors for a
complete description of levels of evidence.
Reconstruction of the anterior cruciate ligament is an effective method of
eliminating anterior tibial subluxation that is associated with rupture of
that
ligament1-17.
Current techniques of anterior cruciate reconstruction employ a variety of
autograft and allograft tissue to replace the injured native ligament.
Reconstruction with an autologous bone-patellar tendon-bone graft is an
effective method of treating anterior tibial subluxation due to a tear of the
anterior cruciate
ligament1,4,5,7,16,18.
However, although this graft type remains the so-called gold standard and is
typically used to reconstruct the anterior cruciate ligament, the potential
morbidity of this procedure (patellofemoral pain, loss of motion, and patellar
fracture)4,5,16
has prompted continued investigation into the use of alternative graft sources
that would yield clinical results equal to those observed after reconstruction
with a bone-patellar tendon-bone graft.
Reconstruction of the anterior cruciate ligament with a hamstring
(semitendinosus and gracilis) tendon autograft has been previously
described2,3,9,10,12-15,19-22.
The strength of the four-strand semitendinosus and gracilis construct has been
shown to be equal to or greater than the strength of a bone-patellar
tendon-bone graft of similar dimension at time
zero23 and with
cyclical loading24.
Most of the published reports on anterior cruciate reconstruction with
autogenous hamstring tendon grafts have described the clinical outcomes in
patients treated with a two or three-tendon
construct2,3,9,11-14,24,
although more recently there have been studies of four-strand
constructs15,19,21,25.
We hypothesized that an arthroscopically assisted reconstruction of the
anterior cruciate ligament with use of a four-strand hamstring tendon
autograft would eliminate symptomatic anterior tibial subluxation and provide
a good functional outcome for patients who have a torn anterior cruciate
ligament. To test this hypothesis, we performed a clinical study to evaluate
the effectiveness of a single-incision, arthroscopically assisted
reconstruction of the anterior cruciate ligament with a four-strand,
double-looped, semitendinosus and gracilis autograft.
Patients and Entry Criteria
The protocol for this study was approved by our institutional review board.
Subsequently, all patients who presented to the senior author (T.L.W.) over a
two-year interval, from 1996 to 1997, with symptomatic anterior tibial
subluxation due to rupture of the anterior cruciate ligament underwent a
standardized evaluation that included a physical examination (measurement of
range of motion, the Lachman test, and the pivot shift test) and standing
anteroposterior and lateral radiographs of the knee. Baseline knee function
scores (the Lysholm score and Tegner score) were obtained at presentation. All
patients who elected to undergo anterior cruciate reconstruction were treated
with a single-incision, arthroscopically assisted reconstruction with a
four-strand semitendinosus and gracilis tendon autograft. One hundred and
twenty-two consecutive patients were treated in this fashion. The operating
surgeon performed no other type of reconstruction for isolated symptomatic
rupture of the anterior cruciate ligament during the study interval. At the
time of surgery, the mean age of the patients was thirty-three years (range,
fifteen to sixty-five years). There were sixty-six male patients and fifty-six
female patients.
Patients who had undergone previous ligament surgery on the affected knee
were excluded from the study. Nine patients (7.4%) had undergone prior partial
medial or lateral meniscectomy in the ipsilateral knee, and two patients
(1.6%) had previously undergone anterior cruciate reconstruction in the
contralateral knee; all of these patients were included in the study group.
However, patients who had had treatment for a symptomatic cartilage lesion
(microfracture, abrasion arthroplasty, or cartilage resurfacing) were excluded
from the study.
Preoperative Physical Examination
Prior to the reconstruction of the anterior cruciate ligament, the mean
knee extension was approximately 0° and the mean knee flexion was 120°
(range, 100° to 140°). All patients had a positive Lachman test (a
grade of =2) and pivot shift test (a grade of =1+). Lachman grading was
based on the relative tibial displacement at 30° of flexion, with grade 1
indicating 0 to 5 mm; grade 2, 6 to 10 mm; and grade 3, >10
mm25. No patient
had a grade-1 result of the Lachman test, 110 patients had grade-2, and twelve
had grade-3. Grading of pivot shift was based on the degree of tibial
reduction during the maneuver, with normal indicating no shift; 1+, glide; 2+,
a severe jump; and 3+, the tibia locked
anteriorly25. The
pivot shift phenomenon was rated as normal in no patients, 1+ in ten, 2+ in
ninety, and 3+ in twenty-two.
Surgical Technique
The anterior cruciate ligament was reconstructed with a single-incision,
arthroscopically assisted method. Antibiotics were given prior to the skin
incision. The limb in which the operation was to be performed was
preliminarily washed with Betadine Surgical Scrub (7.5% povidone-iodine) and
subsequently washed with sponge-sticks containing Betadine solution (10%
povidone-iodine). The leg was wrapped with an adhesive plastic barrier drape
distal to the level of the tibial tubercle. The semitendinosus and gracilis
tendons were harvested from the ipsilateral limb as described
previously26. A
tendon harvester was used in all operations. The graft was prepared by first
removing all muscle fibers from the harvested tendons. The two tendons were
passed through a closed-loop polyester tape that was attached to an Endobutton
(Acufex Microsurgical, Mansfield, Massachusetts), forming four tendon strands,
each with a free end. Each free tendon end was tethered with a nonabsorbable
braided number-1 suture that was placed in an interlocking fashion.
Following preparation of the hamstring graft, diagnostic arthroscopy was
performed. Any meniscal injury was treated prior to the anterior cruciate
reconstruction. A lateral femoral notchplasty was performed in each patient to
facilitate visualization of the posterolateral intracondylar portion of the
lateral femoral condyle. Tibial and femoral tunnels were created on the basis
of the measured diameter of the four-strand hamstring graft from each patient.
Following creation of the femoral tunnel, a 4-mm tunnel was created between
the proximal portion of the femoral tunnel and the anterior femoral cortex.
Following a depth measurement, the Endobutton-polyester suture-loop complex
was created to facilitate femoral fixation of the hamstring graft. In each
patient, a minimum of 25 mm of tendon graft was placed within the femoral
tunnel.
Following stable placement of the Endobutton on the exterior of the femoral
cortex, the knee was flexed and extended while tension was applied to the
graft. The individual graft limbs were tensioned manually prior to application
of tibial fixation. Tibial fixation, which was performed with the knee in
20° of flexion, consisted of staples (fifty-seven patients), a washer and
screw (fifty-seven patients), or an extracortical button (eight patients). The
method of tibial fixation evolved from the washer-and-screw (post) construct
to the anterior cortical staples. This change was implemented at the end of
1996, primarily in response to the dissatisfaction expressed by several
patients early in the study, with the prominent bulge caused by the washer and
screw-head. Buttons were used in operations in which the graft construct did
not exit the tibial tunnel sufficiently for the surgeon to utilize a post or
staple fixation reliably.
In nineteen patients, bioabsorbable polylactic acid interference screws
(DePuy, Warsaw, Indiana) were inserted into the tunnels to provide additional
fixation at the tunnel aperture. These screws were employed only when a
graft-to-tunnel mismatch was apparent. The bioabsorbable interference screws
were used in the femur only in five patients, in the tibia only in seven, and
in both the tibia and the femur in seven.
Associated Procedures at Index Operation
At the time of the anterior cruciate reconstruction, six patients underwent
partial medial meniscectomy and three patients underwent partial lateral
meniscectomy. Ten patients underwent meniscal repair: eight of them had medial
meniscal repair with use of the outside-in technique with number-0 PDS
(polydioxanone suture) (Ethicon-Johnson and Johnson, New Brunswick, New
Jersey)27 and two
had lateral meniscal repair with use of the inside-out technique with the
Acufex meniscal suture repair system (Smith and Nephew, Andover,
Massachusetts)28.
Postoperative Rehabilitation Program
A six-month rehabilitation protocol, similar to a previously described
protocol for anterior cruciate
reconstruction29,
was employed for all patients. Patients began immediate active quadriceps
isometric exercises and passive range-of-motion exercises.
Continuous-passive-motion devices were not used. The patients who underwent
surgery in 1996 were allowed to bear weight on the operatively treated limb,
with the knee in a hinged brace that was locked in full extension, immediately
after surgery. In the second year of the study, patients utilized a brace
postoperatively but were restricted to toe-touch weight-bearing (<20 lb [9
kg]) with two crutches for the first three weeks after surgery. The remainder
of the supervised rehabilitation protocol was the same in the two groups of
patients.
Postoperative Assessment
At the time of follow-up, one examiner performed all of the examinations.
Physical examination included assessment of the range of motion of the knee
with a handheld goniometer, Lachman testing, and pivot shift testing.
Arthrometric measurements of the knee were performed with use of a manual
KT-1000 instrument. Standing anteroposterior and lateral radiographs of the
operatively treated knee were also made, and all patients completed
questionnaires to determine the Lysholm and Tegner outcome scores.
Statistical Methods
Preoperative, intraoperative, and postoperative data were collected and
maintained in a central computer database. Descriptive statistics, the Student
t test (paired or unpaired), chi-square analysis, Fisher exact tests, and
Pearson correlations were appropriately applied. Statistical analysis was
conducted with the SPSS software package (SPSS, Chicago, Illinois).
Significance was established at p < 0.05.
Patient Follow-up
Eighty-five patients (forty-nine male and thirty-six female) were available
for detailed physical examination at a mean of twenty-eight months (range,
twenty-four to forty-two months). At the follow-up examination, functional
scores were obtained with a questionnaire, and all but six patients who had
marked laxity underwent radiographic examination and testing with the KT-1000
arthrometer (MEDmetric, San Diego, California).
Clinical Assessment
At the follow-up examination, seven (8%) of eighty-five patients had a
flexion contracture of <5°. Mean extension was —0.2° (range,
—3° to 0°), and mean flexion was 135° (range, 130° to
145°). Of the eighty-five patients, nine (11%), including six who
sustained a traumatic tear of the hamstring graft postoperatively, had a
positive (grade-2) Lachman test (Fig.
1).
Nine (11%) of the eighty-five patients had a positive pivot shift test (1+
or 2+) at the time of follow-up (Fig.
2). Three of these nine patients reported no episode of knee
trauma, and the remaining six patients reported a recurrence of knee
instability following a specific injury to the operatively treated knee.
The results of the Lachman and pivot shift tests were unaffected by the use
of bioabsorbable screws (in nineteen patients) (Fisher exact test, p =
0.67).
Functional Scores
The Lysholm score improved from a preoperative mean (and standard
deviation) of 55 ± 3 points (range, 15 to 100 points) to a
postoperative mean of 91 ± 2 points (range, 55 to 100 points) (p <
0.01). The Tegner score improved from a preoperative mean of 5 ± 1
points (range, 2 to 10 points) to a postoperative mean of 6 ± 1 points
(range, 3 to 9 points) (p < 0.01).
Arthrometric Testing
Seventy-nine patients underwent testing with the KT-1000 arthrometer at the
follow-up examination. The six patients who had a traumatic rupture of the
anterior cruciate graft were not retested with the KT-1000 arthrometer. Of the
seventy-nine patients tested, sixty-five had =3 mm of laxity, nine had
between 3.1 and 5.0 mm, and five had >5.0 mm. With the numbers available,
the application of bioabsorbable screws (in nineteen patients) had no
demonstrable effect on anterior tibial subluxation as measured with the
KT-1000 arthrometer (Fisher exact test, p = 0.55).
The Pearson correlation coefficient showed a weak inverse correlation
between the Lysholm score and the magnitude of tibial translation as
determined with arthrometric testing (r = —0.134). There was no
significant difference between the arthrometric measurements of the men and
women (p = 0.769, Fisher exact test).
Rehabilitation Protocols
At the time of follow-up, the mean Lysholm and Tegner scores of the
patients who had been permitted full weight-bearing in the immediate
postoperative period were 91 ± 8 and 6 ± 1 points, respectively.
The mean Lysholm and Tegner scores of the patients who had been permitted only
toe-touch weight-bearing for three weeks after the operation were 91 ±
8 and 6 ± 1 points, respectively. There was no significant difference
between the Lysholm (p = 0.84) and Tegner (p = 0.68) scores of these two
groups (Student t test). There was also no significant difference in the
results of the pivot shift tests (p = 0.97) or KT-1000 arthrometric
measurements (p = 0.48) between the two rehabilitation groups.
Radiographic Assessment
One radiologist analyzed the preoperative and follow-up knee radiographs.
The mean Hospital for Special Surgery radiography knee score, which was used
to assess the progression of degenerative
changes1, was 23.5
± 1.5 points preoperatively and 22.5 ± 1.6 points at the time of
follow-up. With the numbers available, this decrease in the score was not
significant according to the Student t test (p = 0.5).
The femoral and tibial tunnels that were created during the anterior
cruciate reconstruction were measured on anteroposterior and lateral
radiographs made at the first postoperative visit, seven to ten days after
surgery, and the measurements were compared with those on knee radiographs
made at the follow-up examination. The maximum width of each tunnel was used
to calculate the tunnel expansion over the follow-up interval. Radiographic
magnification was considered. Expansion of the tibial tunnel (expressed as the
percentage increase in the tunnel width on the follow-up radiographs compared
with the width on the immediate postoperative radiographs) averaged 14%
(range, —10% to 21%) on the anteroposterior radiograph and 17% (range,
—5% to 40%) on the lateral radiograph. Expansion of the femoral tunnel
averaged 29% (range, —10% to 70%) on the anteroposterior radiograph and
8% (range, —12% to 32%) on the lateral radiograph. Negative values for
tunnel expansion reflect tunnel contraction—i.e., the tunnel size at the
time of follow-up was smaller than that noted immediately postoperatively. A
larger degree of tibial tunnel expansion was noted on the lateral radiographs,
and a larger degree of femoral tunnel expansion was noted on the
anteroposterior radiographs (Table
I). The use of bioabsorbable screw fixation had no significant
effect on widening of either the femoral or the tibial tunnel (p = 0.49,
Student t test).
Postoperative Complications
Two (2%) of the eighty-five patients had a deep infection of the knee in
the postoperative period. These patients were treated with arthroscopic
irrigation and débridement, intravenous and oral antibiotics, and
resumption of physical therapy. In both patients, the hamstring graft was
retained. At the follow-up examination, both reported subjective problems with
the knee, and the objective functional scores were good. Another patient
experienced disabling postoperative knee pain that persisted throughout the
six-month rehabilitation period. During the seventh postoperative month, he
was diagnosed as having reflex sympathetic dystrophy. This patient was
subsequently referred for pain management and was treated with serial
sympathetic blockade. Complete resolution of the pain and associated symptoms
was noted at both the one-year and the two-year follow-up interval.
Additional Surgery
Sixteen patients had surgery on the involved knee following the anterior
cruciate reconstruction: five were treated with revision anterior cruciate
reconstruction; two, with arthroscopic irrigation and débridement;
five, with partial meniscectomy; and four, with removal of tibial hardware
(screw and washer). Four of the patients who had partial meniscectomy had
sustained trauma to the knee that resulted in a new meniscal injury. The fifth
patient who underwent subsequent partial meniscectomy had had a meniscal
repair at the time of the anterior cruciate reconstruction. No patient who had
staple fixation underwent hardware removal.
Graft Failure
Six patients (three men and three women) had a traumatic rupture of the
anterior cruciate graft at a mean of 10.7 months (range, four to twenty-four
months) following the surgery (Table
II). Five patients subsequently had a repeat anterior cruciate
reconstruction; the sixth patient tore the graft playing softball and remained
active with use of a knee stabilization brace. One man, in whom the torn
hamstring graft was replaced with a bone-patellar tendon-bone allograft,
subsequently tore the revision graft while playing basketball.
A positive pivot shift (1+ or 2+) developed in the absence of discernible
knee trauma in three patients. Arthrometric KT-1000 testing in each of these
three patients demonstrated tibial translation of >5 mm at 30° of
flexion. One of these three patients reported symptomatic knee instability at
the follow-up examination; this patient was considering a revision anterior
cruciate reconstruction. The remaining two patients did not think that the
involved knee was unstable, despite the positive pivot shift, and had returned
to activity as tolerated.
Successful clinical outcomes following anterior cruciate reconstruction
with a hamstring graft have been reported by many
authors2,3,6,9-15,17,20-22.
Despite these favorable results, concerns regarding the recurrence of
atraumatic knee laxity, bone tunnel widening, the effect of rehabilitation,
gender differences in outcome, and the appropriateness of hamstring grafts for
certain types of athletic activity remain. In our study, anterior cruciate
reconstruction with a four-strand hamstring graft resulted in a successful
clinical outcome in 89% of patients who were available for follow-up. However,
recurrent knee laxity (traumatic and atraumatic) resulting in clinical failure
remains an important concern with this technique.
It is difficult to compare the results of existing studies because of the
variations in the reported surgical
techniques2,3,6,9-15,20-22.
Marder et al. utilized a two-bundle semitendinosus construct and two femoral
Endobuttons in sixty-two patients and reported improved anterior stability
compared with that in patients who had been treated with a single
semitendinosus
bundle10. Hoffmann
et al. reported the results, in sixty-five patients, of anterior cruciate
reconstruction with a doubled-semitendinosus-and-Endobutton construct that was
augmented with an extra-articular lateral
repair8. The authors
reported a 78% rate of good or excellent results initially but noted that knee
laxity increased over time. This observation induced the authors to switch to
a four-strand hamstring construct for anterior cruciate reconstruction.
Nebelung et al. reviewed the results of twenty-nine anterior cruciate
reconstructions with a doubled autogenous semitendinosus tendon and a femoral
Endobutton14. They
graded 66% of the results as normal or nearly normal using the criteria of the
International Knee Documentation Committee.
In the present study, we analyzed the effectiveness of a double-loop
(four-strand) semitendinosus-gracilis graft in eliminating symptomatic
anterior tibial subluxation caused by a torn anterior cruciate ligament.
Anterior tibial subluxation was eliminated in 89% of the patients who were
examined at a mean of 2.3 years postoperatively. The remaining 11% of the
patients (nine) had a 1+ or 2+ pivot shift at the follow-up examination. Six
of those nine patients had sustained a tear of the hamstring graft as a result
of trauma to the knee, whereas a positive pivot shift developed
postoperatively in the absence of a traumatic event in the remaining three (4%
of the patients examined at the time of follow-up). The results in this study
compare poorly with those in previously published outcome studies of hamstring
tendon
grafts6,8-15,17,20-22
or bone-patellar tendon-bone
grafts4,5,7,16
used for anterior cruciate reconstruction.
Bach et al. reported a reoperation rate of 15% in a series of 103 patients
evaluated two years after anterior cruciate reconstruction with a patellar
tendon autograft4.
They reported no traumatic failures but observed a 3% graft-failure rate on
the basis of arthrometric criteria (>5 mm of laxity on testing with a
KT-1000 device). None of those patients demonstrated a positive pivot shift
test. Bach et al. also reported on ninety-seven patients followed for five to
nine years after a two-incision anterior cruciate reconstruction with a
patellar tendon
autograft5. A
positive pivot shift was observed in 16% of those patients, and 4% had
translational differences of >5 mm on KT-1000 arthrometric testing. The
reoperation rate was 26%. No traumatic failure was reported. The 7% prevalence
of traumatic failure in the current study is high compared with the results
reported with the use of patellar tendon
autografts4,5.
An analysis of all of the graft failures in our study
(Table II) did not yield any
insight regarding factors predisposing patients to graft rupture or
attenuation. Patients without symptoms of instability but with objective
anterior tibial subluxation and a positive pivot shift test may have had graft
attenuation prior to the follow-up examination and remained athletically
active by modifying their activity. This fact was reflected by the relatively
low functional scores noted in this group of patients.
It has been suggested that expansion of the tunnels for the anterior
cruciate graft may play a role in the development of atraumatic recurrent knee
laxity following anterior cruciate reconstruction with soft-tissue
grafts30-34.
Tunnel expansion has been seldom described in reports on anterior cruciate
reconstruction with bone-patellar tendon-bone
grafts35.
Conversely, tunnel widening has been extensively reported following anterior
cruciate reconstruction with hamstring
tendons30-34.
Excessive motion of anterior cruciate grafts within the femoral tunnel has
been demonstrated following fixation of the grafts within the
tunnel36. However,
the clinical relevance of this phenomenon following anterior cruciate
reconstruction is unknown. In our series, the femoral and tibial tunnels
widened a mean of 29% and 17%, respectively. These findings are consistent
with those reported by other
authors30-34.
L'Insalata et al. reported widening of the femoral tunnel of 28% to 30% and
widening of the tibial tunnel of 21% to 25% in a radiographic study of
reconstructions of the anterior cruciate ligament with hamstring grafts; they
found no correlation with functional
outcome32. These
results are similar to those recently reported by Simonian et al., more than
one year after anterior cruciate reconstruction with a hamstring graft in
forty patients34.
Nebelung et al. found enlargement of at least 2 mm in 72% of femoral tunnels
and 38% of tibial tunnels in patients examined two years after anterior
cruciate reconstruction in which Endobuttons were used on the femur and
staples were used on the
tibia14. Thus,
while the tunnel expansion observed in our study was similar to that in
previous reports, the clinical implications of this phenomenon remain
unclear.
In our study, the results of KT-1000 arthrometric testing did not correlate
with the functional scores. The KT-1000 measurements reported here are
consistent with those reported by several authors following reconstruction of
the anterior cruciate ligament with a hamstring
graft11,14,33.
Aglietti et al. compared thirty knees in which a torn anterior cruciate
ligament was replaced with a bone-patellar tendon-bone graft with thirty knees
in which the ligament was reconstructed with a semitendinosus and gracilis
tendon graft; they found translation of <5 mm in 13% and 20% of the knees,
respectively2. Other
authors have reported tibial translation of >5 mm in 10% to 18% of patients
following anterior cruciate reconstruction with a hamstring
graft11,14,33.
We found tibial translation of between 3.1 and 5.0 mm in 11% of patients and
of >5 mm in 6% of patients. Of the five patients in our series who had
tibial translation of >5 mm, three had a positive pivot shift test and two
did not. The grafts in the latter two patients were not considered failures.
However, the six patients who had traumatic disruption of the anterior
cruciate ligament graft were not tested with the KT-1000 arthrometer, so this
report underestimates the knee laxity in the study group.
Gender did not play a significant role in the development of graft laxity
or the occurrence of traumatic graft rupture in our series. Recently, however,
Noojin et al. reported a significant difference (p < 0.05) between the
clinical failure rates in women (23%) and men (4%) in a group of sixty-five
patients who had undergone anterior cruciate reconstruction with a four-strand
hamstring
autograft15.
With the rehabilitation protocol used in our study, the majority of
patients returned to a high functional status after six months. No motion
deficits or clinically important knee pain was noted at the follow-up
examination. Other authors have reported success with similar rehabilitation
protocols following anterior cruciate
reconstruction12,29,37,38.
The use of protected weight-bearing for three weeks following surgery did not
significantly affect the functional scores, findings on physical examination,
or results of KT-1000 arthrometric testing. Therefore, we now allow full
weight-bearing with the knee in terminal extension in a brace in the immediate
postoperative period and employ immediate passive range of motion following
the reconstruction.
Two patients had a deep infection of the knee following the anterior
cruciate reconstruction, which is a high infection rate. In their study of
2500 consecutive arthroscopically assisted anterior cruciate reconstructions
performed at our institution, Williams et al. reported an infection rate of
0.03%39. Both of
the patients who had a postoperative infection in our study were treated
effectively with a single arthroscopic knee lavage followed by a combination
of parenteral and oral antibiotics for a total of six weeks. Most importantly,
the hamstring graft was preserved in both patients, and a complete functional
recovery was noted at the follow-up examination.
Clinically relevant patellofemoral pain or loss of knee motion has been
reported following anterior cruciate reconstruction with the patellar
tendon4,5,39,
but neither was observed in our study. The elimination of knee instability and
the functional scores in our series were consistently good, but the rate of
traumatic rupture of the graft (7%) is a cause for concern. The prevalence of
traumatic rupture of bone-patellar tendon-bone grafts used for anterior
cruciate reconstruction has been reported to be 0% to
2%4,5,16.
The graft rupture rate in our study was markedly higher than those rates for
patellar tendon autografts. As one of the goals of anterior cruciate
reconstruction is the durable restoration of knee stability, the issue of
rupture of hamstring grafts remains a concern. In a recent meta-analysis
comparing outcomes of anterior cruciate reconstruction with either hamstring
tendon or patellar tendon grafts, Yunes et al. reported significantly (p <
0.01) higher postoperative activity levels and greater static stability
following the surgery with the patellar tendon
grafts40. However,
it is important to note that no graft that is currently used for anterior
cruciate reconstruction is ideal. Although Yunes et al. noted better stability
after the use of patellar tendon grafts, such grafts are associated with a
higher prevalence of patellofemoral pain than are soft-tissue
grafts4,5,16.
We did not observe any clinically relevant knee pain or motion loss at the
time of follow-up. The absence of such morbid findings following anterior
cruciate reconstruction with a hamstring graft may make this method of
reconstruction more desirable for certain patients (i.e., those with chronic
patellofemoral pain or patellofemoral cartilage disorders) despite the
somewhat increased risk of recurrent knee laxity noted in this study.
We found that a four-strand semitendinosus-gracilis autograft eliminated
symptomatic anterior tibial subluxation associated with a torn anterior
cruciate ligament in 89% of the patients who were available for follow-up.
Significant improvements in functional scores were noted. Objective findings
of knee stability were inferior to those reported after anterior cruciate
reconstructions with bone-patellar tendon-bone autografts, but these findings
did not correlate with functional scores. The prevalence of traumatic graft
rupture was 7%, and the overall objective failure rate was 11%. Radiographs
demonstrated tunnel widening in all patients; however, there were no
progressive degenerative changes in the treated knees.
Note: The authors thank Andrew Collins, MD, and John Cavanaugh,
PT, for their assistance with this study.
Buss DD, Warren RF, Wickiewicz TL,
Galinat BJ, Panariello R. Arthroscopically assisted reconstruction of the
anterior cruciate ligament with use of autogenous patellar-ligament grafts.
Results after twenty-four to forty-two months. J Bone Joint Surg
Am.1993;75:
1346-55.751346
1993
Aglietti P, Buzzi R, Zaccherotti G,
De Biase P. Patellar tendon versus doubled semitendinosus and gracilis
tendons for anterior cruciate ligament reconstruction. Am J Sports
Med.1994;22:
211-8.22211
1994
[CrossRef]
Aglietti P, Buzzi R, Menchetti PM,
Giron F. Arthroscopically assisted semitendinosus and gracilis tendon
graft in reconstruction for acute anterior cruciate ligament injuries in
athletes. Am J Sports Med.1996;24:
726-31.24726
1996
[PubMed][CrossRef]
Bach BR Jr, Levy ME, Bojchuk J,
Tradonsky S, Bush-Joseph CA, Khan NH. Single-incision endoscopic anterior
cruciate ligament reconstruction using patellar tendon autograft. Minimum
two-year follow-up evaluation. Am J Sports Med.1998;26:
30-40.2630
1998
[PubMed]
Bach BR Jr, Tradonsky S, Bojchuk J,
Levy ME, Bush-Joseph CA, Khan NH. Arthroscopically assisted anterior
cruciate ligament reconstruction using patellar tendon autograft. Five- to
nine-year follow-up evaluation. Am J Sports Med.1998;26:
20-9.2620
1998
[PubMed]
Barber FA. Tripled
semitendinosus-cancellous bone anterior cruciate ligament reconstruction with
bioscrew fixation. Arthroscopy.1999;15:
360-7.15360
1999
[PubMed][CrossRef]
Deehan DJ, Salmon LJ, Webb VJ, Davies
A, Pinczewski LA. Endoscopic reconstruction of the anterior cruciate
ligament with an ipsilateral patellar tendon autograft. A prospective
longitudinal five-year study. J Bone Joint Surg Br.2000;82:
984-91.82984
2000
[PubMed][CrossRef]
Hoffmann F, Friebel H, Schiller
M. [The semitendinosus tendon as replacement for the anterior cruciate
ligament]. Zentralbl Chir.1998;123:
994-1001. German.123994
1998
[PubMed]
Maeda A, Shino K, Horibe S, Nakata K,
Buccafusca G. Anterior cruciate ligament reconstruction with multistranded
autogenous semitendinosus tendon. Am J Sports Med.1996;24:
504-9.24504
1996
[PubMed][CrossRef]
Marder RA, Raskind JR, Carroll M.
Prospective evaluation of arthroscopically assisted anterior cruciate ligament
reconstruction. Patellar tendon versus semitendinosus and gracilis tendons.
Am J Sports Med.1991;19:
478-84.19478
1991
[PubMed][CrossRef]
Meystre JL, Vallotton J, Benvenuti
JF. Double semitendinosus anterior cruciate ligament reconstruction:
10-year results. Knee Surg Sports Traumatol Arthrosc.1998;6:
76-81.676
1998
[PubMed][CrossRef]
Muneta T, Sekiya I, Ogiuchi T,
Yagishita K, Yamamoto H, Shinomiya K. Effects of aggressive early
rehabilitation on the outcome of anterior cruciate ligament reconstruction
with multi-strand semitendinosus tendon. Int Orthop.1998;22:
352-6.22352
1998
[PubMed][CrossRef]
Muneta T, Sekiya I, Yagishita K,
Ogiuchi T, Yamamoto H, Shinomiya K. Two-bundle reconstruction of the
anterior cruciate ligament using semitendinosus tendon with endobuttons:
operative technique and preliminary results.
Arthroscopy.1999;15:
618-24.15618
1999
[PubMed][CrossRef]
Nebelung W, Becker R, Merkel M, Ropke
M. Bone tunnel enlargement after anterior cruciate ligament reconstruction
with semitendinosus tendon using Endobutton fixation on the femoral side.
Arthroscopy.1998;14:
810-5.14810
1998
[PubMed][CrossRef]
Noojin FK, Barrett GR, Hartzog CW,
Nash CR. Clinical comparison of intra-articular anterior cruciate ligament
reconstruction using autogenous semitendinosus and gracilis tendons in men
versus women. Am J Sports Med.2000;28:
783-9.28783
2000
[PubMed]
O'Brien SJ, Warren RF, Pavlov H,
Panariello R, Wickiewicz TL. Reconstruction of the chronically
insufficient anterior cruciate ligament with the central third of the patellar
ligament. J Bone Joint Surg Am.1991;73:
278-86.73278
1991
[PubMed]
Otero AL, Hutcheson L. A
comparison of the doubled semitendinosus/gracilis and central third of the
patellar tendon autografts in arthroscopic anterior cruciate ligament
reconstruction. Arthroscopy.1993;9:
143-8.9143
1993
[PubMed][CrossRef]
Shelbourne KD, Gray T. Anterior
cruciate ligament reconstruction with autogenous patellar tendon graft
followed by accelerated rehabilitation. A two- to nine-year followup.
Am J Sports Med.1997;25:
786-95.25786
1997
[PubMed][CrossRef]
Goradia VK, Grana WA. A
comparison of outcomes at 2 to 6 years after acute and chronic anterior
cruciate ligament reconstructions using hamstring tendon grafts.
Arthroscopy.2001;17:
383-92.17383
2001
[PubMed][CrossRef]
Siegel MG, Barber-Westin SD.
Arthroscopic-assisted outpatient anterior cruciate ligament reconstruction
using the semitendinosus and gracilis tendons.
Arthroscopy.1998;14:
268-77.14268
1998
[PubMed][CrossRef]
Spicer DD, Blagg SE, Unwin AJ, Allum
RL. Anterior knee symptoms after four-strand hamstring tendon anterior
cruciate ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc.2000;8:
286-9.8286
2000
[CrossRef]
Zysk SP, Kruger A, Baur A, Veihelmann
A, Refior HJ. Tripled semitendinosus anterior cruciate ligament
reconstruction with Endobutton fixation: a 2-3-year follow-up study of 35
patients. Acta Orthop Scand.2000;71:
381-6.71381
2000
[PubMed][CrossRef]
Hamner DL, Brown CH Jr, Steiner ME,
Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the
anterior cruciate ligament: biomechanical evaluation of the use of multiple
strands and tensioning techniques. J Bone Joint Surg
Am.1999;81:
549-57.81549
1999
Simonian PT, Williams RJ, Deng XH,
Wickiewicz TL, Warren RF. Hamstring and patellar tendon graft response to
cyclical loading. Am J Knee Surg.1998;11:
101-5.11101
1998
[PubMed]
Williams RJ 3rd, Wickiewicz TL,
Warren RF. Management of unicompartmental arthritis in the anterior
cruciate ligament-deficient knee. Am J Sports Med.2000;28:
749-60.28749
2000
[PubMed]
Pagnani MJ, Warner JJ, O'Brien SJ,
Warren RF. Anatomic considerations in harvesting the semitendinosus and
gracilis tendons and a technique of harvest. Am J Sports
Med.1993;21:
565-71.21565
1993
[CrossRef]
Rodeo SA, Warren RF. Meniscal
repair using the outside-to-inside technique. Clin Sports
Med.1996;15:
469-81.15469
1996
Cooper DE, Arnoczky SP, Warren
RF. Meniscal repair. Clin Sports Med.1991;10:
529-48.10529
1991
[PubMed]
Howell SM, Taylor MA. Brace-free
rehabilitation, with early return to activity, for knees reconstructed with a
double-looped semitendinosus and gracilis graft. J Bone Joint Surg
Am.1996;78:
814-25.78814
1996
Clatworthy MG, Annear P, Bulow JU,
Bartlett RJ. Tunnel widening in anterior cruciate ligament reconstruction:
a prospective evaluation of hamstring and patella tendon grafts.
Knee Surg Sports Traumatol Arthrosc.1999;7:
138-45.7138
1999
[PubMed][CrossRef]
Jansson KA, Harilainen A, Sandelin J,
Karjalainen PT, Aronen HJ, Tallroth K. Bone tunnel enlargement after
anterior cruciate ligament reconstruction with the hamstring autograft and
endobutton fixation technique. A clinical, radiographic and magnetic resonance
imaging study with 2 years follow-up. Knee Surg Sports Traumatol
Arthrosc.1999;7:
290-5.7290
1999
[CrossRef]
L'Insalata JC, Klatt B, Fu FH, Harner
CD. Tunnel expansion following anterior cruciate ligament reconstruction:
a comparison of hamstring and patellar tendon autografts. Knee Surg
Sports Traumatol Arthrosc.1997;5:
234-8.5234
1997
[CrossRef]
Segawa H, Omori G, Koga Y, Matsueda
M, Tomita S, Kikui H.Bone tunnel enlargement after anterior
cruciate ligament reconstruction using hamstring tendons. Presented as
a poster exhibit at the Annual Meeeting of the American Academy of Orthopaedic
Surgeons; 2000 Mar 15-19; Orlando, FL.
2000
Simonian PT, Erickson MS, Larson RV,
O'Kane JW. Tunnel expansion after hamstring anterior cruciate ligament
reconstruction with 1-incision EndoButton femoral fixation.
Arthroscopy.2000;16:
707-14.16707
2000
[PubMed][CrossRef]
Fink C, Zapp M, Benedetto KP, Hackl
W, Hoser C, Rieger M. Tibial tunnel enlargement following anterior
cruciate ligament reconstruction with patellar tendon autograft.
Arthroscopy.2001;17:
138-43.17138
2001
[PubMed][CrossRef]
Hoher J, Livesay GA, Ma CB, Withrow
JD, Fu FH, Woo SL. Hamstring graft motion in the femoral bone tunnel when
using titanium button/polyester tape fixation. Knee Surg Sports
Traumatol Arthrosc.1999;7:
215-9.7215
1999
[CrossRef]
MacDonald PB, Hedden D, Pacin O,
Huebert D. Effects of an accelerated rehabilitation program after anterior
cruciate ligament reconstruction with combined semitendinosus-gracilis
autograft and a ligament augmentation device. Am J Sports
Med.1995;23:
588-92.23588
1995
[CrossRef]
Shelbourne KD, Nitz P.
Accelerated rehabilitation after anterior cruciate ligament reconstruction.
Am J Sports Med.1990;18:
292-9.18292
1990
[PubMed][CrossRef]
Williams RJ 3rd, Laurencin CT, Warren
RF, Speciale AC, Brause BD, O'Brien S. Septic arthritis after arthroscopic
anterior cruciate ligament reconstruction. Diagnosis and management.
Am J Sports Med.1997;25:
261-7.25261
1997
[PubMed][CrossRef]
Yunes M, Richmond JC, Engels EA,
Pinczewski LA. Patellar versus hamstring tendons in anterior cruciate
ligament reconstruction: a meta-analysis. Arthroscopy.2001;17:
248-57.17248
2001
[PubMed][CrossRef]