Clinical Results and Risk Factors for Reinjury 15 Years
After Anterior Cruciate Ligament Reconstruction: A Prospective Study of
Hamstring and Patellar Tendon Grafts

Leys T, Salmon L,
Waller A, Linklater J, and Pinczewski L. Am J Sports Med. 2012; 40 (3). 595-605.

Commonly seen in
young athletes, anterior cruciate ligament (ACL) rupture is often treated by
surgical reconstruction of the ligament. The aims of this surgery are to
restore the joint kinematics, limit episodes of instability, and return the
patient to preinjury levels of activity. While the aims of ACL reconstructions
are the same, the optimal graft type used in this reconstruction, is still a
debated issue. Therefore, Leys and colleagues conducted a prospective cohort
study to compare the outcomes of patellar tendon (PT) and hamstring tendon (HT)
autografts assessed at 2, 5, 7, 10, and 15 years post-surgery. A total of 180 patients
(90 consecutive patients in each group) were initially included in the study.
At the 15-year follow-up visit, 51 patients with HT were available and 43
patients with PT were available for full assessment (subjective and clinical
review, over 70 patients/group were available for just a subjective review at
15 years). The decision of which graft would be used was based on what time
period (mid-October 1993: HT autograft, Oct 1993-Nov 1994: PT autograft) the
patient’s initial consultation took place, with all surgeries being performed
by one surgeon. The follow-up assessments included the International Knee
Documentation Committee (IKDC) knee ligament evaluation (assesses signs and
symptoms as well as knee function), Lysholm knee score (assesses knee function),
clinical assessment (Lachman, anterior drawer, etc.), instrumented laxity
testing, range of motion, kneeling pain using a visual analog scale, and
single-legged hop test. Radiographs were also taken at each follow-up visit. Patients
who received a HT autograft had superior outcomes at 15-years post-surgery
compared to patients with PT autografts with respect to IKDC score, activity
level (based on patient reports:, strenuous vs. moderate vs. light), kneeling
pain, range of motion, single-legged hop test, and radiologic changes (using
IKDC grading system). Since the 10-year follow-up visit, more patients with PT
autografts may have developed extension deficits and patients with PT
autografts experienced a decline in single-leg hop performance.  Interestingly, the PT autograft was found to
have better results with respect to clinical ligament stability measurements at
15 years post-surgery follow-up.

Overall, this study
presents interesting insight into the long-term results comparing both HT and
PT autografts. While the results of this study showed patient with HT
autografts had significantly better results in function, pain levels, activity
levels, and radiologic changes, the authors note that this change was seen
primarily between 10 and 15 year follow-up. The authors suggest that these
differences after long-term follow-up could be in part related to the onset and
progression of osteoarthritis. Clinically, this study presents and interesting
case for patients who are concerned about long-term knee outcomes to receive HT
autografts as they appear to have less degenerative change and better
functional outcomes at a 15 year follow-up. While this may be true, the PT
autograft did show better performance (although not statistically significant)
with respect to instrumental stability measures (once again showing a
discordance between knee stability measures and other outcomes). How does this
information change your current counseling strategy? Would you be more inclined
to suggest a HT graft knowing that the long-term functional outcomes appear to
be better?

Written by: Kyle
Reviewed by:  Jeffrey Driban

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Leys T, Salmon L, Waller A, Linklater J, & Pinczewski L (2012). Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. The American Journal of Sports Medicine, 40 (3), 595-605 PMID: 22184280