ACL reconstruction with hamstring graft may reduce flexion strength vs. patellar graft
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Key takeaways:
- ACL reconstruction with hamstring tendon graft may yield decreased knee flexion strength vs. reconstruction with patellar tendon graft.
- Outcomes were assessed at a minimum follow-up of 18 years.
Published results showed patients who underwent ACL reconstruction with a hamstring tendon graft had decreased knee flexion strength compared with patients who received a patellar tendon graft at long-term follow-up.
Marko Popovic, MD, from the department of orthopedics at Trondheim University Hospital in Norway, and colleagues performed a randomized, prospective multicenter study of 114 patients (mean age, 27 years) who underwent surgery for an ACL rupture between 2001 and 2004 with a minimum follow-up of 18 years.
Of patients available for final analysis, 49 were randomly assigned to undergo ACL reconstruction with double-looped semitendinosus and gracilis grafts and 47 were randomly assigned to undergo ACL reconstruction with bone-patellar tendon-bone grafts.
Popovic and colleagues noted 71 patients were available for clinical examination at follow-up, with five patients excluded for ACL revision and two patients excluded for total knee replacement. They noted 25 patients had undergone additional surgery other than ACL revision or TKR.
Outcome measures included anterior knee laxity, isokinetic muscle strength, range of motion (ROM), patient-reported outcome measures (PROMs) and radiographic osteoarthritis.
At follow-up, Popovic and colleagues found no significant differences between the groups for anterior knee laxity, ROM, PROMs or radiographic OA. However for patients in the hamstring tendon group, isometric knee flexion torque was reduced by 10.7% at 60° per second and mean total knee flexion work was reduced by 17.2% at 60° per second compared with patients in the patellar tendon group. Popovic and colleagues noted these differences were statistically significant.
Popovic and colleagues concluded patients who undergo ACL reconstruction with hamstring tendon grafts may be at risk for “a permanent reduction” in knee flexion strength.
Perspective
Back to TopChad D. Lavender, MD, and Timothy E. Hewett, PhD
We read with great interest the recent study published in the American Journal of Sports Medicine entitled “Reduced knee flexion strength 18 years after ACL reconstruction with hamstring tendon vs. patellar tendon” by Marko Popovic, MD, Jon Olav Drogset, MD, PhD, and colleagues. This study examined 114 patients with ACL rupture between 2001 and 2004 who were randomly assigned to reconstruction with either a bone-patellar tendon-bone (BPTB) graft or a hamstring tendon graft. Patients were operated on at four major hospitals, and secondary outcomes included “18-year follow-up evaluation of isokinetic testing of muscle strength, patient-reported outcome measures and an assessment of radiographic osteoarthritis using the Kellgren-Lawrence classification,” the authors wrote.
This study appears to be a multiple time reanalysis of the same cohort of patients to compare the results after using either BPTB grafts or hamstring tendon grafts 18 years after ACL reconstruction.
We applaud these authors for the publication of this important study. The authors’ conclusion was “flexion strength in the hamstring group was significantly reduced in the operated knee after 18 years. There were no significant differences between the groups regarding subjective outcomes, patient-reported outcomes, range of motion, clinical and instrumented knee laxity and the development of osteoarthritis.”
This study is of major importance in that it shows that after nearly 2 decades after the use of autograft hamstring tendons, significant strength deficits remain. In our view, this study is another in the long list of studies that support against the long-term use of patients’ own hamstrings tendons for ACL reconstruction. One concern is how many times has this same or similar dataset been mined? What are the validity and limits for these reanalyzes? Why do the reported findings differ for each reanalysis?
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