2017 ISAKOS Biennial Congress ePoster #1104

 

Anatomic ACL Reconstruction via Independent Tunnel Drilling: A Systematic Review of Randomized Controlled Trials Comparing Patellar Tendon and Hamstring Autografts

Michael G. Ciccotti, MD, Philadelphia, PA UNITED STATES
Michael G. Ciccotti, MD, Philadelphia, PA UNITED STATES
Eric Secrist, BS, Philadelphia, PA UNITED STATES
Fotios P. Tjoumakaris, MD, Egg Harbor Township, NJ UNITED STATES
Kevin Freedman, MD, Bryn Mawr, PA UNITED STATES

Rothman Institute, Philadelphia, PA, UNITED STATES

FDA Status Not Applicable

Summary

The purpose of this systematic review was to collect the highest level of evidence comparing anatomic ACL reconstruction via independent tunnel drilling using patellar bone-tendon-bone (BTB) and hamstring (HT) autografts.

Abstract

Background

Despite how often anterior cruciate ligament reconstruction (ACL) is done, there is still no consensus on the optimal graft. Both bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts are used extensively with similar clinical results and low complication rates. In the literature, biomechanical studies suggest that anatomic ACL reconstruction places higher graft forces on the reconstructed ACL compared to more vertical transtibial grafts. However, there is some recent data to suggest that despite anatomic placement, the failure rate could actually be higher with anatomic ACL reconstruction compared to traditional transtibial techniques. It is unclear if there may be differences in failure rates with anatomic ACL reconstruction comparing BTB and HT autografts. We attempted to address this issue by conducting a systematic review of randomized controlled trials that compared outcomes following BTB and HT ACL reconstruction using anatomic drilling techniques.

Purpose

The purpose of this systematic review was to collect the highest level of evidence comparing anatomic ACL reconstruction via independent tunnel drilling using patellar bone-tendon-bone (BTB) and hamstring (HT) autografts.

Methods

We performed a systematic review of clinical trials that randomized patients to ACL reconstruction with either BTB or HT autografts with minimum two-year follow-up. Only trials utilizing independent tunnel drilling techniques for both autografts were eligible for inclusion. Study design, demographics, surgical technique, rehabilitation protocol, and clinical outcomes were compiled. PRISMA guidelines were followed. Quality assessment was performed using the Coleman Methodological Scale (CMS).

Results

Seven published studies reporting on six randomized controlled trials (RCTs) met the inclusion criteria. No study reported a difference in re-rupture rate between BTB and HT. BTB-reconstructed knees experienced a greater incidence of anterior knee pain or crepitus in 2/7 trials and radiographic evidence of degenerative change in 3/7 trials. HT-reconstructed knees demonstrated increased instrumented laxity in 2/7 trials and less knee flexion strength postoperatively.

Conclusions

Based on the data presented in these Level I and II studies, clinical outcome scores and re-rupture rate show minimal differences. Both grafts possess theoretical advantages: BTB may have greater instrumented stability and improved knee flexion while HT may have lower rates of anterior knee pain and degenerative change. This study collects the highest level of evidence for anatomic ACL reconstruction using BTB and HT grafts. Minimal differences were found between autograft choices when using anatomic ACL reconstruction techniques and the existing literature suggests that both remain valid options.

Level of Evidence: Systematic Review, Level II