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  • Jade Elkind

I’m Getting ACL Surgery. What Are They Going To Do?


With people living longer, and more active lives, it is no surprise that many people are undergoing ACLR. We are fortunate to be able to undergo a surgery that can dramatically improve our function and help us heal from injuries.


In the stone age, someone who blew out an ACL would probably get eaten!

However, with the myriad of surgical types out there, it is easy to see why someone would have a hard time figuring out what type of surgery to undergo and which surgeon to see.


I will preface it with this however: This information is by NO MEANS exhaustive, for there are many conflicting studies and the details of the techniques are much more specific than I have provided. I am also not an advocate of one technique over another, for I believe that much of the outcome has to do with patient prior level of activity, adherence to precautions, the type and duration of rehabilitation following surgery, the skill and experience of the surgeon, the overall condition of the tissue used for the graft, and the patient’s motivation.


So without further ado, here it is:


Hamstring Tendon Autografts (HT)

ACL reconstruction can be accomplished via both the gracilis and semitendinosus tendons (Frank et al) or via the semitendinosus tendon (Davarinos et al).

The gracilis is a part of the inner thigh which helps to pull your leg inwards and bend your knee.


The semitendinosus is a part of your hamstring, which assists with bending the knee and extending your hip.


According to Baawa-Ameyaw et al., since hamstring tendon autografts are from the patient’s own tissue, this minimizes the risk of graft infection, thereby limiting the immune response and allowing for faster graft integration. Also, since the incisions to harvest these grafts are smaller than those for the bone-patellar tendon-bone grafts, they are associated with less anterior knee pain.


According to Conte et al., the main limitations of hamstring tendon autografts were hamstring weakness, unpredictable graft size and possible saphenous nerve injury.


Bone-Patalla Tendon-Bone Autografts (BPTB)


BPTB autographs use a portion of the patellar tendon for ACL reconstruction. The patellar tendon is the fibrous band that resides below your kneecap and inserts into the bone called the tibia.


BPTB autographs heal from bone-to-bone, therefore the fixation may be more rigid and faster than hamstring tendon grafts (Baawa-Ameyaw et al.), however, anterior knee pain was more frequent in the patellar tendon group (Guglielmetti et al).

In a 24-month post-op evaluation of soccer players with a mean age of 25.1 years and an average time between injury and surgery of 4 months, a study did not show differences in soccer players who received patellar tendon vs hamstring tendon grafts. (Guglielmetti et al).


Furthermore, according to a review by Hoge et al., the studies did not show long-term differences (the mean follow up time was 14.79 years) with knee laxity or graft failure between patellar tendon and hamstring tendon autografts, but radiographic and subjective outcomes indicated that patients with patellar tendon autografts may experience more knee pain while kneeling and osteoarthritis.

Quadriceps Tendon (QT)


This uses a graft harvested from the quadriceps tendon, which resides above the kneecap (patella).


Compared to the hamstring tendon grafts, a type of quadriceps tendon graft (a double-layered, partial-thickness, soft tissue quadriceps tendon graft AKA “dlQUAD” technique) showed lower failure rates and small increases in Tegner*** and IKDC (The International Knee Documentation Committee)**** scores (Eggeling et al).


Also, according to a meta-analysis done by Mouarbes et al., the QT autograft had similar outcomes in regard to function and graft survival as the patellar tendon and hamstring autografts. However, the quadriceps tendon autograft was less painful at the harvest site than the patellar tendon autograft and demonstrated better functional outcome scores than the hamstring autograft.


Allograft


Allografts are taken from donor tissue.


There are some advantages of using an allograft: There is no damage to the graft site (since it is not from the individual’s own tissue) and there is no risk of hamstring weakness or knee pain as seen with the hamstring and patellar tendon autografts (Baawa-Ameyaw et al). They are also associated with a lesser operative time, smaller incisions, and less post-operative pain levels (Kim et al). However, since it is from a donor tissue there is a risk of disease transmission, and it may take longer for the body to incorporate the graft into its native tissue (Baawa-Ameyaw et al). They are also not as strong as autografts, so they may only be appropriate for patients undergoing revision ACL surgery or in those who only want to return to lower demand activities (Kim et al).


In fact, according to Kaeding et al., the use of allografts in first time ACL repair was associated with a 5.2 times greater risk of graft failure compared to patellar tendon autografts.


However, also according to Kaeding et al., with increasing age by the mid 30’s, there was no significant difference of the allograft vs autograft tear risk.



ACL Repair with Lateral extra-articular tenodesis (ACLR with LET) and ACL Repair with Anterolateral Ligament Reconstruction (ACLR with ALLR)


ACL Repair with Lateral extra-articular tenodesis (ACLR with LET): Uses a strip of the iliotibial band (ITB) to assist with stability.


ACL Repair with Anterolateral Ligament Reconstruction (ACLR with ALLR): This type of ACL repair involves the use of the anterolateral ligament (ALL) to assist with rotary stability of the knee.


For those who have significant laxity of their ligaments, hyperextension of the knee, a very positive pivot shift test* (a hands-on maneuver that tests for ACL disruption) and compete in sports that require a lot of pivoting on their leg, a ACLR with extra-articular tenodesis may be undergone. The most common include ACLR with LET and ACLR with ALLR (Spencer et al).


A meta-analysis conducted by Devitt et al researched the functional outcomes of the LET at a minimum of a two year follow up. ACLR with LET was associated with more knee stability than ACLR alone and there was also a reduction in the risk of a positive pivot test. Furthermore, a systematic review done by Beckers et al demonstrated that using either ACLR with ALLR or LET significantly improved the rotary stability of the knee and decreased antero-posterior (front to back) translation.


Conclusion


As you can see, there are many factors that contribute to the type of graft used and the outcomes, and as I had mentioned earlier, this blog is by no means totally inclusive. As our medicine progresses, so will the types of surgeries and the outcomes.


If you have been having a knee issue or want to avoid having to deal with any ACL injuries, reach out and let’s talk!


References:


Baawa-Ameyaw J, Plastow R, Begum FA, Kayani B, Jeddy H, Haddad F. Current concepts in graft selection for anterior cruciate ligament reconstruction. EFORT Open Rev. 2021 Sep 14;6(9):808-815. doi: 10.1302/2058-5241.6.210023. PMID: 34667652; PMCID: PMC8489469.

Beckers L, Vivacqua T, Firth AD, Getgood AMJ. Clinical outcomes of contemporary lateral augmentation techniques in primary ACL reconstruction: a systematic review and meta-analysis. J Exp Orthop. 2021 Aug 12;8(1):59. doi: 10.1186/s40634-021-00368-5. PMID: 34383156; PMCID: PMC8360253.

Conte EJ, Hyatt AE, Gatt CJ, Jr, Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy 2014;30:882–890.

Davarinos N., O'Neill B.J., Curtin W. A brief history of anterior cruciate ligament reconstruction. Adv Orthop Surg. 2014;2014:6.

Devitt BM, Bell SW, Ardern CL, et al.. The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: a systematic review with meta-analysis and best-evidence synthesis. Orthop J Sports Med 2017;5:2325967117731767.

Eggeling L, Breer S, Drenck TC, Frosch KH, Akoto R. Double-Layered Quadriceps Tendon Autografts Provide Lower Failure Rates and Improved Clinical Results Compared With Hamstring Tendon Grafts in Revision ACL Reconstruction. Orthop J Sports Med. 2021 Dec 5;9(12):23259671211046929. doi: 10.1177/23259671211046929. PMID: 34901287; PMCID: PMC8652188.

Frank RM, Hamamoto JT, Bernardoni E, Cvetanovich G, Bach BR Jr, Verma NN, Bush-Joseph CA. ACL Reconstruction Basics: Quadruple (4-Strand) Hamstring Autograft Harvest. Arthrosc Tech. 2017 Aug 14;6(4):e1309-e1313. doi: 10.1016/j.eats.2017.05.024. PMID: 29354434; PMCID: PMC5622412.

Hoge CG, Matar RN, Khalil LS, Buchan JA, Johnson CM, Grawe BM. Outcomes Following Anterior Cruciate Ligament Reconstruction with Patellar Tendon vs Hamstring Autografts: A Systematic Review of Randomized Controlled Trials with a Mean Follow-up of 15 Years. Arch Bone Jt Surg. 2022 Apr;10(4):311-319. doi: 10.22038/ABJS.2021.53662.2668. PMID: 35721585; PMCID: PMC9169734.

Guglielmetti LGB, Salas VER, Jorge PB, Severino FR, Duarte A, de Oliveira VM, Cury RPL. Prospective and Randomized Clinical Evaluation of Hamstring Versus Patellar Tendon Autograft for Anterior Cruciate Ligament Reconstruction in Soccer Players. Orthop J Sports Med. 2021 Sep 24;9(9):23259671211028168. doi: 10.1177/23259671211028168. PMID: 34604426; PMCID: PMC8485166.

Kaeding CC, Pedroza AD, Reinke EK, et al.; MOON Consortium. Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions from the MOON cohort. Am J Sports Med 2015;43:1583–1590.

Kim HS, Seon JK, Jo AR. Current trends in anterior cruciate ligament reconstruction. Knee Surg Relat Res. 2013 Dec;25(4):165-73. doi: 10.5792/ksrr.2013.25.4.165. Epub 2013 Nov 29. PMID: 24368993; PMCID: PMC3867608.

LARS. ACL reconstruction with LARS ligament surgical technique. http://www.lars-ligaments.com. Published 2009 Accessed October 31, 2016.

Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. Am J Sports Med. 2019 Dec;47(14):3531-3540. doi: 10.1177/0363546518825340. Epub 2019 Feb 21. PMID: 30790526.

Sinagra ZP, Kop A, Pabbruwe M, Parry J, Clark G. Foreign body reaction associated with artificial LARS ligaments: a retrieval study. Orthop J Sports Med 2018;6:2325967118811604.

Spencer L, Burkhart TA, Tran MN, et al.. Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med 2015;43:2189–2197.


*** A scale that provides a standardized method in determining the level of activity prior to injury and level of activity post injury that can be documented on a numerical scale.

**** a knee-specific patient-reported outcome measure

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