Quality of life and clinical outcome comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: An 11-year follow-up of a randomized controlled trial
Sajovic M, Strahovnik A, Dernovsek MZ, Skaza K. Am J Sports Med. 2011 Oct;39(10):2161-9.
The goals of anterior cruciate ligament (ACL) reconstruction surgery are to decrease symptoms, increase function, and to return to pre-injury activity status. There are numerous techniques and grafts utilized for ACL reconstruction, including autografts or allografts. Autografts are frequently selected, and can consist of patellar tendon (PT) or semitendinosus and gracilis (STG) tendons. Currently, there is no consensus as to which graft is the best option for optimal outcomes. Therefore, this group conducted a prospective, randomized controlled trial to compare the surgical outcomes of PT and STG autografts among 64 patients (32 receiving each graft). In this article the authors report the 11-year follow-up data for 52 patients that were available for evaluation (27 patients with STG autograft and 25 patients with PT autograft). During the follow-up visit, patients were assessed on multiple outcome and quality of life measures. Outcomes included the Lysholm knee (patient-reported knee evaluation), Short Form-36 (general health questionnaire), and International Knee Documentation Committee (IKDC) scores (clinician-reported functional outcome), as well as single-legged hop test. Clinical measures included a Lachman’s, anterior drawer, pivot shift, and KT-1000 tests, as well as radiographs. There were no significant differences between the PT and STG groups in graft ruptures, number of patients participating at their preinjury level of activity, Lysholm, Short Form-36, IKDC, single-legged hop test, Lachman’s, or KT-1000 scores. The PT group had significantly greater positive pivot shift tests, as well as a possibly greater incidence of osteoarthritis on radiograph (84% versus 63% with knee osteoarthritis).
As clinicians, this study demonstrates that ACL reconstruction utilizing either the PT or STG has comparable and favorable patient outcomes in function and quality of life. Each choice has negative consequences (e.g., tendinitis, weakness) but with similar outcomes. Functional demands of patients should be taken into consideration when making this decision. It is also important to note that a large number of knees in both groups had osteoarthritis, despite no apparent link to poorer quality of life or function. It will take a larger sample size to determine if knees with PT grafts are at a greater risk for osteoarthritis compared to knees with STG grafts. Future studies should also assess biomechanics and joint biochemistry to determine how these factors influence the risk of osteoarthritis with both graft types. This study provides additional evidence that knee injuries place the joint at an increased risk for developing osteoarthritis. What are your clinical experiences with the long-term performance of different ACL grafts?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
Sajovic M, Strahovnik A, Dernovsek MZ, & Skaza K (2011). Quality of Life and Clinical Outcome Comparison of Semitendinosus and Gracilis Tendon Versus Patellar Tendon Autografts for Anterior Cruciate Ligament Reconstruction: An 11-Year Follow-up of a Randomized Controlled Trial. The American Journal of Sports Medicine, 39 (10), 2161-9 PMID: 21712483
I have not had very many opportunities to see multiple outcomes with both PT and STG grafts; however I was told by a surgeon that he likes to use Hamstring grafts over PT grafts because he feels that the PT will hurt more throughout the rehabilitation process then the Hamstring, but he did bring up a good point within the athletic population. 1 factor that aids in his decision is the type of athlete he will be performing the surgery on. Athlete's that will more then likely have an aggressive rehabilitation he will use the PT, so that the athlete will have no choice but to go slower due to a slight increase of pain, and vice versa. He also said that he has seen more overcome the extension lag that may come with ACL reconstruction in those had the Hamstring Graft compared to those with the patella tendon. Overall he spoke more highly of the STG then PT graft.
Despite the study not finding significance in all the outcome measures investigated, the fact that 82% of STG and 72% PT autograft reconstructions returned and maintained pre-injury level of activity following 11 years is an important statistic. Even the subjective assessments for IKDC and Lysholm were consistently measured normal and excellent respectively. Because the results obtained were from a single surgeon, comparing these results to everyone else receiving ACL reconstruction from the thousands of surgeon’s available makes generalizing the results tough. The success of each patient’s rehabilitation may also be contributable to an accelerated rehab protocol for each patient. Early motion and strengthening will help to avoid residual dysfunction of the knee. I previously worked in a physical therapy clinic for 3 years involved in the rehabilitation of both hamstring and patellar tendon ACL reconstruction. In my experiences the two techniques yield equally good results dependent on the compliance of the patient. Each technique has its own set of challenges such as hamstring weakness with STG graft and anterior tenderness with PT graft but overall the end product is favorable. As an athletic trainer for 7 years, I have been around athletes that have received both techniques and overall every one of them returned to full activity and participation.
Jenna & Brandon-Thanks for your comments! I agree, in the short-term it seems that we are doing a relatively good job of returning to pre-injury function levels, and understanding the cons of either graft choice. My concern in in the long-term; after these athletes are DONE playing competitively. Have either of you (or anyone for that matter) seen any trends as far as long-term functional outcomes of either graft selection? I have noticed anecdotally, athletes that have selected an allograft have had less issues during competitive years, and seemingly more problems as they become further removed from the sport. Has anyone else seen anything similar?
I have seen positive and negative outcomes with both techniques. The surgeons at my previous school preferred the PT technique, and most of our athletes chose the PT procedure. Some of the athletes had significant problems with tendonitis that inhibited their rehab progress. However, just as many had no complications. The one athlete I saw who had a STG procedure lost a significant amount of ROM and strength that eventually prevented her from returning to sport. However, most of the evidence points to this technique as the preferred technique. I feel as though the surgeon's preference and his/her familiarity with a particular procedure may be important factors to consider in addition to the athlete's goals (return to competitve sport or ADL/recreational activity)when choosing between the PT and STG techniques.
Abby- I couldn't agree with you more when you say it depends on the surgeon and their familiarity with the technique or preference. I would be interested to see if their preference is based largely on who they did their fellowship under. I rarely see our surgeon change his preference based on the sort the athlete is trying to return to play to. Just out of curiosity, what sport did the athlete that had the poor outcomes with the STG play?