Purpose: The optimal autograft choice for ACL reconstruction remains controversial. Twelve recently published reviews comparing Patellar Tendon (PT) to Hamstring Tendon (HT) autografts in ACL reconstruction vary in their methodology, quality and application of sensitivity analyses. The present review and meta-analysis follows the rigorous methodology of the Cochrane Collaboration of Systematic Reviews and includes more recent trials that utilize modern surgical techniques and concealed randomization.
Method: Randomized Clinical Trials (RCT) and Quasi-randomized Trials (QRCT) with a minimum 2-year follow-up comparing PT with HT autografts in patients undergoing primary ACL reconstruction were included. Non-English articles were professionally translated. Four electronic databases were searched from 1969-present. Bibliographies and proceedings of major orthopaedic meetings were handsearched. Two teams of investigators independently reviewed all citations, selected relevant studies, extracted the data and assigned quality scores. Consensus was achieved within and between each team for all stages of the review process.
Results: Three hundred and twenty-six citations were originally identified with the search criteria. Following rigorous review, 26 relevant studies were identified. Nine were excluded due to missing information, inadequate follow-up, ongoing trials or low quality scores, leaving 17 studies included in the final analysis. Outcomes related to stability (Lachman test, instrumented laxity, and pivot shift) showed trends towards improved stability with PT reconstruction. When QRCTs were excluded there was a significant difference favoring PT reconstructions only with respect to the pivot shift test. All other outcomes were similar between the PT and HT reconstructions including IKDC categories, anterior knee pain (trend in favor of HT), re-rupture rate, and activity levels. No information was available to distinguish between the outcome of acute and chronic reconstructions, long term information or validated patient based outcomes.
Conclusion: The current literature fails to demonstrate significant differences in multiple outcomes comparing PT to HT reconstruction of the ACL. The overall quality of trials is questionable and fails to use validated patient based outcomes or sufficiently long-term results to assess the development of osteoarthritis.
