Introduction:Anterior cruciateligaments (ACL) are one of the four main ligaments responsible for ensuring thestability of the tibiofemoral joint. It is typically injured by active sportplayers in a ‘non-contact deceleration or change of direction with a fixed footthat produces a valgus twisting injury’. 1 Younger active patients are the most common cohort affectedby this injury. It is heavily linked tosports like football and basketball and the mechanism usually depends on theligament strength being overcome by anterior tibial forces that can result inquadriceps contraction and hyperextension. 1 Acutely, a ‘poppingsensation’, pain and rapid onsets (< 2 hours) of tense and large effusionsare suggestive of an ACL injury.
2 However, chronically the mainissue typically relates to knee instability. 3 The history and examination –particularly special tests like the anterior drawer, Lachman’s and pivot shift– are usually diagnostic with magnetic resonance imaging (MRI) selected as thebest imaging modality due to its superior assessment of soft tissues provingmost helpful in detecting ACL tears and other soft tissue pathology associatedwith ACL injuries such as meniscal tears. 3Management is normallydictated by the grading of the ligament injury (Figure 1) and the symptomaticimpact on patient quality of life. Thiscan vary substantially between elite athletes and sedentary elderly patientswho put variable load through the joint.
In the latter cohort, conservative methods are heavily favoured whichare reliant on physiotherapy to maintain range of movement and hamstring andquadriceps activation. However, surgeryis often indicated if they are physically active and/or describe problematicknee instability. Reconstructive surgery is often necessary for completeruptures of the ligament as they are usually unable to heal. Historically these procedures have used anautograft from the iliotibial band but following a move away from open surgerytowards delicate arthroscopic methods, a selection of other grafts are nowconsidered. 4 The most commongraft types include: autografts (hamstring, patellar and quadriceps tendons),allografts from donor tissues and/or synthetic equivalents. 4Autografts, specifically hamstring tendons (HS) in the UK, are most commonly usedand they, along with bone-patellar tendon-bone grafts (PT), will provide thecomparative focus of the review.
Hamstring tendons havebeen reported as unstable, cause increased laxity and more prevalent graftfailures. 5, 6 This has resulted in patellar tendon grafts, in somecases, being favoured due to their bony attachments at either end. This is thought to improve the fixation ofthe tendon at both the tibial and femoral sides and provide ‘superiorosteointegration and healing properties’. 7 However, harvesting PTgrafts involves resecting the middle portion of the tendon and this can, andhas, led to donor site morbidity manifesting as anterior and/or kneelingpain.
Advances in ‘new fixation methodsof HS grafts has helped minimise graft fixation issues that were responsiblefor graft failure or a higher knee laxity’ in a significant cohort of HS patientswho experienced problems. 7 As a result, with a prominent shortfallof HS grafts removed, HS cohorts could now experience reduced complications andgraft site morbidity relative to patients receiving PT grafts. All papers are expected to show improvedoutcomes for patients following intervention but the purpose of this review isto try and identify which, if either, improves outcomes the most and which, ifeither, has the least associated morbidity. To achieve this, provisional reading of the literature has identifiedthe most common outcome measures.
Given the time constraints placed on thisreview, the five main parameters chosen to ensure the most holistic assessmentof outcome are: pain, laxity, quality of life (QOL), activity level andprevalence of osteoarthritis (OA). Themost frequently used outcome assessors for each are shown in Figure 9. A Consultant KneeSurgeon outlined the debate around different autograft types as topical andwith an interest in sport medicine – sport injuries in particular – this seemedan appropriate issue to review. Inretrospect, there appears to be no obvious ‘need’ for a literature review giventhe meta-analyses and cohort studies done within the last two years. 8, 9 However, this paper is seeking to accesspapers that may have been missed and focusses only on randomized control trialswith the aim of adding to the evidence base or affirming their findings. No guidelines could be found on NationalInstitute for Clinical Excellence (NICE), Royal College of Surgeons (RCS) orBritish Orthopaedic Association (BOA) websites for autograft selection.
As a result, instead of comparing against acurrent guideline, this review will help inform the practice and autograftselections of the lower limb orthopaedic staff at the Royal Liverpool andBroadgreen University Hospital Trust (RLBUH).