Graft Selection for ACL Reconstruction

GRAFT SELECTION in ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION:
Bone-Patella Tendon-Bone vs. Hamstring Grafts

R.L.Morgan-Jones, M.J.Cross

Is the graft chosen for ACL reconstruction important? YES!

The graft chosen should

1) Provide adequate fixation to allow rehabilitation,

2) Allow anatomic re-creation of the ACL in both size and location

3) Have adequate initial strength to survive the uncertainties of graft regeneration.

Bone-Patella Tendon-Bone (B-PT-B) grafts have the best initial fixation by using interference screws to produce rigid bone-to-bone fixation. Hamstring fixation is soft tissue to bone via sutures and is less rigid.

Both B-PT-B and Hamstring grafts should allow re-creation of the ACL in both size and location although this is largely dependent on the experience and expertise of the surgeon.

Both B-PT-B and Hamstring grafts need to undergo regeneration or they will fail. The initial fixation and tensioning of the graft both effect the biology of healing. In this respect B-PT-B graft has an advantage and theoretically has the best chance of functional regeneration.

Bone-Patella Tendon-Bone Grafts

Advantages: Excellent initial and long-term fixation,Better overall stability

Disadvantages: Increased anterior knee pain, Two incisions (plus arthroscopy portals)

Hamstring Grafts

Advantages: Lower incidence of anterior knee pain and crepitus, Single incision (plus arthroscopy portals)

Disadvantages: Less secure initial and long-term fixation,Increased knee laxity after reconstruction

Aglietti et al., AJSM 22: 211, 1994

In prospective studies comparing B-PT-B vs. Hamstring grafts it was found that both grafts are good choices in ACL reconstruction but that B-PT-B graft provides more overall knee stability than hamstring grafts.

Otero et al., arthroscopy, 1993

GOLD STANDARD

At present the "Gold Standard' ACL reconstruction is B-PT-B Graft

Johnson R.J., The Knee, Dec.1999
Cleveland Clinic Foundation

We use the Bone-Patella Tendon-Bone graft in the majority of patients requiring ACL reconstruction because we believe it gives the best guarantee of a successful outcome. This is based both on reviewing the scientific literature and extensive orthopaedic experience.

Acknowledgment : We thank Dr Robert Johnson for allowing us to use his paper on ACL Reconstruction and Graft Selection in preparing this article.