The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Anterior Cruciate Ligament Reconstruction with a Four-Strand Hamstring Tendon Autograft"
by Riley J. Williams III, MD, et al.

Commentary & Perspective by
Christopher D. Harner, MD*,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

The authors of this relatively large retrospective series report on the clinical outcomes of patients undergoing hamstring anterior cruciate ligament reconstruction. The strengths of the study include that it comprises a consecutive series of patients who underwent reconstruction by a single surgeon and that it had a relatively good follow-up (70%, or eighty-five patients of a total of 122 patients). The radiographic data on tunnel expansion was well done and complete. The relative weaknesses of the paper include its retrospective design, lack of any comparison group (a patellar tendon auto or allograft group, for example), unclear preoperative subjective data, use of the Lysholm score but not the IKDC (International Knee Documentation Committee) score, variable hamstring fixation, and lack of any information on the thirty-seven patients (30%) who were not seen in follow-up: were these patients younger; were they male or female; did they have any complications that were not included?

It is not clear at what point after the initial injury the patients underwent anterior cruciate ligament reconstruction. Did these patients have predominantly chronic anterior cruciate ligament deficiency with multiple re-injuries, or did they have relatively acute single injuries? Did the patients who had chronic deficiency with multiple re-injuries do any better or worse than patients with a single injury?

The data regarding tunnel expansion seem to agree with other reports^1,2, and the question remains, does this commonly identified phenomenon following hamstring anterior cruciate ligament reconstruction make any clinical difference? In my experience, if tunnel expansion does exist in the setting of a failed graft, then it is often necessary to bone-graft the tunnels prior to revision surgery.

From their objective data, we have good information on the KT 1000 arthrometric measurements in the group that was seen in follow-up (70%), but the authors did not include in their final analysis the nine patients who had graft failure. This certainly would have changed the overall results of the KT testing. We have been given no data on functional strength (hop test, vertical jump) or on side-to-side differences in hamstring strength. These data have important ramifications not only for this study but also for future studies that the authors may wish to conduct if they compare these patients with another group of patients who have received different anterior cruciate ligament reconstruction techniques.

In both Figures 1 and 2, the authors compared the results of the preoperative Lachman and pivot shift tests that had been performed under anesthesia to the results of postoperative examinations that had been performed in the office. This difference most likely skewed the reported laxity patterns to favor significant improvement after reconstruction. It is important to note that this study did not utilize the IKDC subjective or objective scoring system, which is currently the most accepted outcome tool. I suspect that during the initial enrollment of the patients in 1996 and 1997, the authors were not using the IKDC system, but the use of the system was certainly established in 1998 and 1999 and during the follow-up period.

In summary, the results of this article are in agreement with other articles on hamstring anterior cruciate ligament reconstruction with similar reoperation and failure rates^3-5. It would have been helpful to know how this group of patients did in comparison with a similar group of patients in whom another graft, such as patellar tendon autograft, was used. Finally, it would be informative to know the authors' current preferences for graft selection for anterior cruciate ligament surgery. Has this study changed the way they approach anterior cruciate ligament surgery, and have they modified any of their techniques or postoperative rehabilitation protocols?

*The author did not receive grants or outside funding in support of research or preparation of this manuscript. The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Clatworthy MG, Annear P, Bulow JU, Bartlett RJ. Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc. 1999;7:138-45.
2. L'Insalata JC, Klatt B, Fu FH, Harner CD. Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc. 1997;5:234-8.
3. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med. 1991;19:478-84.
4. Noojin FK, Barrett GR, Hartzog CW, Nash CR. Clinical comparison of intraarticular anterior cruciate ligament reconstruction using autogenous semitendinosus and gracilis tendons in men versus women. Am J Sports Med. 2000;28:783-9.
5. Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: A meta-analysis. Arthroscopy. 2001;17:248-57.