Athletes With Bone-Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria Than Athletes With Hamstring Tendon Autograft or Soft Tissue Allograft : Secondary Analysis From the ACL-SPORTS Trial PMID: 11973544 P atellar tendon ruptures are the third most com- (Am J Sports Med, 1999). Sherman O.H., Banffy M.B. Use of the patellar tendon autograft in ACL reconstruction became prevalent over three decades ago. A primary patellar tendon repair is performed with ipsilateral semitendinosus autograft augmentation and bidirectional suture anchor fixation. Consistent size and shape of the graft, as well as ease of harvest are arguments in favour of the patellar tendon autograft. Am J Sports Med 2000; 28:651-8. Brace-free rehabilitation protocols that incorporate immediate motion of the knee … Anterior cruciate ligament reconstruction: which graft is best? Patella Tendon Autograft To me, the gold standard of ACL reconstruction is the patella tendon autograft and should be considered for most people in their teens, 20’s and for many in their 30’s or 40’s. More recent large systematic reviews involving thousands of patients comparing patellar tendon to hamstring tendon grafts do show a slightly lower re-tear rate when using patellar tendon grafts with the difference being about 1-2 %. Prodromos C.C., Joyce B.T., Shi K., Keller B.L. —– Learn more about the other types of grafts here —–. Full knee ROM (compared to uninvolved This occurs to some degree in most cases, but usually in just a small to moderate sized area lateral to the incision, which is significantly longer than a hamstring graft incision. Knee 2005; 12:225-30. J Am Acad Orthop Surg 2005; 13:197-207. Authors of meta-analyses fail to agree on subjective differences in anterior knee pain or return-to-activity level10, 14-16. Many studies have also found that the risk of developing osteoarthritis after ACL reconstruction with patellar tendon is significantly higher than when other grafts are used. Chapter 42 Bone-Patellar Tendon-Bone Autograft Anterior Cruciate Ligament Reconstruction Robert A. Magnussen, Joseph P. DeAngelis, Kurt P. Spindler Advantages of and Contraindications to Bone-Patellar Tendon-Bone Autograft Procedures Although general indications for anterior cruciate ligament (ACL) reconstruction are discussed elsewhere in this … This key knee ligament is commonly torn during sports activities. —– Learn more about the hamstring tendon autograft here —–. J Bone Joint Surg Am 1993; 75:1795-803. The overall width of the patellar tendon determines the size of the graft, which usually consists of the central 10 mm, to a maximum of 40% of the total width. New York: Springer-Verlag, 2004. The Athletes With Bone-Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria Than Athletes With Hamstring Tendon Autograft or Soft Tissue Allograft : Secondary Analysis From the ACL-SPORTS Trial. A meta-analysis of 47,613 patients. Central third patellar tendon autografts require harvesting of a tibial tubercle and patellar bone plug, through either a longitudinal midline incision or two small transverse incisions over the bony insertions of the patellar tendon. It is harvested from the central one-third of the patellar tendon along with a bone block from the patella at one end and a bone block from the tibia (shin bone) at the other end (the tendinous portion of the graft is too short to use alone). It is usually 9-10 mm in width and 8-9 cm in length. Bmj 2006; 332:995-1001. Although infrequent, complications with patellar tendon autograft include patellar fractures, patellar tendon ruptures, kneeling pain, tendonitis, and numbness from injury to the infrapatellar branch of the saphenous nerve6. The aim of this procedure is to restore patellar height and prevent extensor lag. The graft is then passed through the tibial tunnel from the medial to the lateral side (Fig 8). Anterior knee pain has long been thought to be associated with harvest of the patellar tendon, but some authors have suggested that it may be more related to loss of motion and poor rehabilitation techniques rather than graft choice7-9. This key knee ligament is commonly torn during sports activities. Normal gait pattern 3. However, as is the case with the hamstring graft, smaller female patients often do not have a wide enough patellar tendon to make this graft option feasible. After anterior cruciate ligament (ACL) surgery, graft healing in patellar tendon (PT) and hamstring autograft (HS) is characterised by a remodelling process. Patellar Tendon Autograft . The patellar tendon averages between 25 to 30 mm in width. Bone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) reconstruction. Reconstructed ACL graft rupture more commonly occurred in the hamstring autograft than in the patellar tendon autograft. Reports on greater posterior tibial slope (PTS) and its relationship to subsequent anterior cruciate ligament (ACL) injury show conflicting results; it has not been studied much in patients after ACL reconstruction with patellar tendon autograft (PTG). Animal studies show that the patellar tendon graft will heal in the bone tunnel at an average of 6 weeks, whereas a soft tissue graft, like the hamstring graft, will take an average of 12 weeks. 9. 1. Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. 2017; 475: 2459– 2468. 16. Because there is a block of bone at each end, the graft will heal more quickly to the femoral and tibial bone tunnels drilled to accept the graft. Improving orthopaedic care, education and research using Internet technologies. © 1999-2017 Orthogate. Advantages• Heals quickly• Strong• Lower re-tear rates• Higher rate of return to sport• Less graft looseness, Disadvantages• Higher risk of anterior knee pain and pain when kneeling• Higher risk of developing osteoarthritis later in life• Longer recovery of knee extension and quadriceps strength, The Banff Sport Medicine Foundation is a registered charity with a Mission to “Prevent, treat, rehabilitate, and research musculoskeletal and sport injuries among people of all ages and abilities.”. Management of a failed primary repair or chronic patellar tendon tear can … We suggest that the hamstring tendon autograft is a safe, effective, and acceptable choice for patellar tendon reconstruction, and that it affords good ligament reconstruction. Tendon-healing in a bone tunnel. Successful ACL reconstruction depends on a number of factors including meticulous tunnel placement, surgical technique and aggressive rehabilitation. This graft is also known as a bone-patellar tendon-bone (BPTB) graft. Analytical results showed satisfactory function after patellar tendon reconstruction with the use of hamstring tendon autografts. The anterior cruciate ligament (ACL) is a major stabilizer of the knee joint. Also, because bone from the patella is taken with the graft, there is a chance this could weaken the bone resulting in a fracture. A meta-analysis of stability after anterior cruciate ligament reconstruction as a function of hamstring versus patellar tendon graft and fixation type. Biau D.J., Tournoux C., Katsahian S., Schranz P.J., Nizard R.S. 13. Learn more! The patellar tendon is also a strong graft, with human cadaver studies showing a load to failure of up to 3,000 N, although there is no reason to assume that it is any stronger than an adequately sized hamstring graft at the end of the healing process. The initial graft tensile strength of bone-patellar tendon-bone autograft is 2977 N with a stiffness of 620 N/mm. Numerous studies show that there is a significantly higher risk of anterior knee pain and kneeling pain with this graft compared to others. As with hamstring grafts, harvesting patellar tendon grafts can result in skin numbness. Recently, several systematic reviews were published suggesting that there is no significant evidence to indicate that any one graft is superior with respect to stability, failure rates and clinical scores.11-13 Graft site morbidity, specifically hamstring weakness in the 4-bundle hamstring autograft and increased kneeling pain in the patellar tendon group was seen consistently in the studies evaluated. Goldblatt J.P., Fitzsimmons S.E., Balk E., Richmond J.C. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. This graft is also known as a bone-patellar tendon-bone (BPTB) graft. Some authors routinely harvest the contralateral tendon, allowing faster rehabilitation with no long-term adverse effects2, 3. To harvest quadriceps tendon-bone full-thickness autograft, 4- to 5-cm incision is made in the sagittal plane perpendicular to the superior pole of the patella, starting 4 to 5 cm proximal to the patella and directing distally up to 0.5 to 1 cm over the patellar dorsal surface. Quadriceps strength greater than 80% of uninvolved side 2. Obtaining an adequate graft specimen while minimizing donor site morbidity is the goal of graft harvest. It has remained the most popular graft choice because of its strength characteristics, rigid initial fixation and favourable clinical outcomes. Background: Bone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) reconstruction. Patellar Tendon Autograft Rehabilitation Protocol The intent of this protocol is to provide the clinician with a guideline of the post-operative reha-bilitation course of a patient that has undergone an anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft. A systematic review of autografts for anterior cruciate ligament reconstruction. 12. It has remained the most popular graft choice because of its strength characteristics, rigid initial fixation and favourable clinical outcomes. Patellar tendon rupture is an infrequent cause of disability in patients younger than 40 years, with chronic injury and repeat procedures creating difficulty in facilitating healing. Arthroscopy 2001; 17:248-257. If you have orthopedic information that you would like to share with the Orthogate Community, please register/login and submit your news, event, job, article, case or workshop from the Submit Content menu under the My Account area. There is also a tiny risk (0.25%) of experiencing a rupture of the patellar tendon after graft harvest. A circular or straight-blade oscillating saw is then used to harvest the bone plugs, with care taken not to notch the patella transversely to prevent fracture. 6. Use of hamstring autograft to reinforce the repair has been reported to strengthen the repair construct in patients with previous failure or chronic injury. Arthroscopy 1997; 13:229-32. Arthroscopy 2005; 21:1202. As recently as 2000, over 80% of members of the American Academy of Orthopaedic Surgeons still preferred using the central third bone-patellar tendon-bone graft in ACL reconstruction and it remains the gold-standard to which all other graft choices are compared1. Am J Sports Med 1994; 22:324-7. 2. The patellar tendon autograft is the second most common choice used for an ACL reconstruction autograft after the hamstring tendon autograft. The described MPFL reconstruction with the use of the medial 1/3rd of patella tendon is Rodeo S.A., Arnoczky S.P., Torzilli P.A., Hidaka C., Warren R.F. Patellar tendon autograft has long been considered the gold standard, and no conclusive data is currently available to support this claim10. and Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? Patellofemoral problems after anterior cruciate ligament reconstruction. Clin Orthop Relat Res 1996:91-9. Despite the vast amount of literature on graft selection and outcomes in ACL reconstruction, there are few randomized controlled studies comparing the graft choices using contemporary fixation methods. Anterior cruciate ligament reconstruction with bone–patellar tendon–bone autograft has long been considered the graft preference for young, active patients with anterior cruciate ligament injuries. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. If this is the case, your surgeon may recommend another graft option. Bone-patellar tendon-bone autograft versus hamstring autograft anterior cruciate ligament reconstruction in the young athlete: a retrospective matched analysis with 2–10 year follow-up Randy Mascarenhas • Michael J. Tranovich • Eric J. Kropf • Freddie H. Fu • Christopher D. Harner 2 FiberWire locking whipstitches are placed in the distal patellar tendon remnant. All Rights Reserved, Management of lower limb (aka knee) injuries in youth athletes, Managing pain after your orthopedic surgery, Prevent, treat, rehabilitate, and research musculoskeletal and sport injuries among people of all ages and abilities.”. Patellar tendon ruptures are a relatively uncommon injury and account for roughly 3% of all injuries to the tendon ligament complex of the knee. This is over 1.5 times the strength and 4 … Johnson D.H. ACL Made Simple. 11. We select patients for four-strand hamstring tendon reconstruction as a function of age, sex, and type of sports activities. The patellar tendon autograft is the second most common choice used for an ACL reconstruction autograft after the hamstring tendon autograft. For many years, this graft has been considered by some to be the “gold standard” when it comes to ACL grafts for the following reasons (truthfully, there is really no one autograft that is significantly superior to the others). A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. All rights reserved. Sign up for our newsletter and get expert injury prevention tips, a sneak peek of our latest research, inspiring patient stories, and more, direct to your inbox. 8. Finally, several studies have shown that it is more difficult to regain full knee extension post-operative with use of this graft, and this may also contribute to the delay in quadriceps muscle recovery.
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