1. Comparing Outcomes after Anterior Cruciate Ligament Reconstruction using either Patellar or Hamstring Tendon Autografts: A Systematic Review By Michael Sheridan and Are Martin Kallaak

2. Glossary ACL – Anterior Cruciate Ligament BPTB – Bone-Patellar-Tendon-Bone IKDC – International Knee documentation Comittee ST – Semitendinosus STG – Semitendinosus Gracilis CONSORT – Consolidated Statement for Reporting Trials

3. ACL reconstructive surgery  In USA about 50 000 to 75 000 ACL reconstructions are performed each year

4. ACL reconstructive surgery  Involves replacing the torn ACL with graft tissue

5. ACL reconstructive surgery  Autograft= Graft tissue harvested from patients own body  Allograft= Graft tissue harvested from cadaver

6. ACL reconstructive surgery  Most commonly Autografts is harvested from the Patellar tendon or the Semitendinosus and/or Gracilis tendons

7. ACL reconstructive surgery

8. Preparation of ST/G graft

9. ACL reconstructive surgery  Most ACL surgeries today are performed arthroscopically

10. ACL reconstructive surgery

11. Introduction  BPTB grafts has been considered the golden standard

12. Introduction  There exists little evidence to support this

13. Introduction  Previous studies have found no significant differences between BPTB and ST/G grafts

14. Introduction  Current level of evidence is inconsistent regarding best overall outcomes

15. Objective  To investigate if there is a significant difference between the two techniques  0 hypothesis= There is a significant difference favoring use of BPTB graft  Hypothesis= There is no significant difference between the 2 techniques.

16. Research question Is there a difference in outcomes of knee scoring systems after ACL reconstruction using either Patellar or Hamstring tendon grafts?

17. Methods Literature search  Medline and Google Scholar  Keywords used: ACL reconstruction, Patellar, Hamstring, Functional Outcomes, Clinical Trial, IKDC, Lysholm and Cincinnatti

18. Methods Outcome Measurements  IKDC (International Knee documentation Scale)  Lysholm  Tegner activity scale  Cincinnati  KT-1000

19. Methods Inclusion criteria  English language  Published within last 10 years  IKDC, Lysholm, Tegner or Cincinatti as outcome measures  Randomized studies only  At least 2 year follow up  Identical mode of rehabilitation within each article  Artroscopic intervention  Score 80% or higher on the CONSORT checklist for RCT’s  Hamstring and Patellar grafts is compared directly

20. Methods

21. Evaluation of studies  CONSORT checklist for RCT’s  80% was required  For inclusion randomization needed to be described according to CONSORT

22. Methods IKDC  Valid and reliable widely used knee evaluation questionnaire

23. Methods IKDC  Consists of an objective and subjective part

24. Methods IKDC Scoring:  A- Normal Function  B- Nearly Normal  C- Abnormal  D- Severely Abnormal

25. Methods Lysholm Knee Rating System  1 page scoring sheet

26. Methods Lysholm Knee Rating System  Filled out by patient

27. Methods Lysholm Knee Rating System  Proven reliable as a one time measurement but not for detecting changes over time

28. Methods Lysholm Knee Rating System  Total score of 100 points possible

29. Methods

30. Cincinnati  Found to be valid and reliable  useful for detecting changes between evaluations

31. Methods Tegner activity scale  simple 10 point rating scale  Good level of test-retest reliability and responsiveness

32. Methods KT-1000 arthrometer  Instrument to measure knee ligament laxity in the saggital plane  Consistency of measurements of anterior knee laxity between examiners is considered as fair to moderate

33. Results  17 articles where judged relevant for our topic  After our inclusion criteria was applied we were left with 10  After Evaluation with the CONSORT checklist 7 articles were left for inclusion

34. Results  Since only RCT’s were included the randomization process needed to be described in detail

35. Results Included articles  Aglietti P, Biddau F, Buzzi R, Giron F, Sasso F, 2004, Anterior Cruciate Ligament Reconstruction: Bone-Patellar-Tendon-Bone compared with Double Semitendinosus and Gracilis Tendon Grafts. A Prospective Randomized Clinical Trial, J. Bone and Joint Surgery 86: pp 2143-2155  Al-Kussary I M, Al-Misfer A R K, Al- Mutairi H Q, Ghafar S A, Ibrahim S A R, Noor T A E, 2005,Clinical evaluation of Arthroscopically assisted anterior cruciate ligament reconstruction: Patellar tendon versus Gracilis and semitendinosus autograft, The Journal of Arthroscopy and Related Surgery 21,4:pp 412-417  Aune A K, Holm I, Krogstad Jensen H, Risberg M A, Steen H, 2001, Four-Strand Hamstring Tendon Autograft Compared with Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction: A Randomized Study with Two Year Follow-Up, The American Journal of Sports Medicine, Vol. 29, No.6: pp 722-728  Ejerhed L, Kartus J Karlsson J, Köhler K, Sernert N, 2003, Patellar Tendon or Semitendinosus Tendon Autografts for Anterior Cruciate Ligament Reconstruction? A Prospective Randomized Study with a Two Year Follow-Up, The American Journal of Sports Medicine, Vol 31, No.1: pp 19-25   Feller J A, Webster K E, 2003, A Randomized Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine Vol.31, No. 4:pp 564-573  Harilainen A, Jansson K A, Linko E, Sandelin J, 2003, A prospective randomized study of Patellar versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction, The American Journal of Sports Medicine, Vol. 31, No. 1:pp 12-18  Laxdal G, Hansson L, Heidvall M, Karlsson J, Kartus J, Ejerhed L, 2005, A prospective randomized comparison of bone-patellartendon-bone and hamstring grafts for anterior cruciate ligament reconstruction, The Journal of Arthroscopy and Related Surgery 21,1:pp 34-42

36. Results Total patient population

37. Results Lysholm Scores

38. Results  Mean Tegner scores at 2 year Follow–up. 4 articles. No statistically significant differences between groups.

39. Results  Mean side to side anterior laxity at ≥ 2 year follow-up. KT1000

40. Results  Cincinnati functional score  Aune et al (2001) was the only article to use the Cincinnati functional score but reported no difference between the groups

41. Results  IKDC 1. Used in 5 of 7 articles. 2. No statistically significant differences between groups. 3. 2 studies reported that no patients scored D (severely abnormal) in either group

42. Results: summing up the outcome measures.  BPTB 1. IKDC = no difference between other graft types. 2. Cincinnati = no difference between the groups. 3. Tegner = scoring higher than ST but lower than STG. 4. Lysholm = Highest scoring, not clinically significant. 5. KT 1000 = same average score as STG and slightly better than ST. No significance

43. Results: summing up the outcome measures.  ST 1. IKDC = no difference between other graft types. 2. Cincinnati = no difference between the groups. 3. Tegnor = Lowest scoring. No significance 4. Lysholm = Lowest scoring, not clinically significant. 5. KT 1000 =Highest laxity Score. No significance

44. Results: summing up the outcome measures.  STG 1. IKDC = no difference between other graft types. 2. Cincinnati = no difference between the groups. 3. Tegnor = Highest scoring. No significance 4. Lysholm = No Values 5. KT 1000 =less laxity than ST group, same score as BPTB. Differences not significant.

45. Results Patellafemoral symptoms  5 studies reported that kneeling pain was significantly more common in the BPTB group

46. Results Patellafemoral symptoms  Not to be confused with anterior knee pain which showed no difference between the groups at 2 year follow up

47. Discussion  No significant difference found with any of the knee scoring systems

48. Discussion  Graft type is not the only factor affecting outcomes  Factors not evaluated by our outcome measures may reveal significant differences

49. Discussion  External validity and RCT’s  ACL reconstructions under different circumstances occur but are never included in randomized trials  Skill and experience of the surgeon

50. Discussion Limitations of this review  not considering differences in fixation methods between studies  Variations in rehabilitation between studies  Not enough high quality RCT’s with identical methodology

51. Discussion What could be done to improve the level of evidence?  larger population  Longer follow up  Comparing other factors related to ACL  Difficult to achieve

52. Conclusion  The use of BPTB as the golden standard is not backed up by sufficient evidence  Both techniques shows significant improvement in outcomes

53. Clinical Significance The patellar tendon graft is not recommended for:  people requiring a lot of kneeling in daily life  Athletes that are involved in sports that puts a lot of strain on the patellar tendon

54. Clinical Significance  Due to slightly better stability associated with the BPTB graft it may be recommended for athletes involved in sports that require a lot of pivoting and twisting.  ST/G grafts is recommended for patients with patellafemoral problems

55. Clinical Significance  The PT together with the patient should perform an evaluation of the individual needs in order to find what graft type is best

56. Aknowledgements We would like to thank: Our coach Jesse Aarden and our client Niels Veeldhuijzen for their assistance and expertise We are also thankful to the facilities of VU Amsterdam for supplying access to scientific articles

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