Tibial Rotational Kinematics and Neuromuscular Control After Anterior Cruciate Ligament Reconstruction with the Bone–Patellar Tendon–Bone Autograft Versus Quadrupled Hamstrings

Stavros Ristanis, Constantina Moraiti, Franceska Zampeli, Dimitrios Giotis, Sofia Xergia, Spiros Georgiou, Nick Stergiou, Anastasios D Georgoulis
European Musculoskeletal Review, 2011;6(4):280-285
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Abstract

The purpose of this review is to present our previous research on the effectiveness of the two most popular autografts: the bone–patellar tendon–bone (BPTB) and the semitendinosus/gracilis (ST/G) in restoring rotational kinematics and neuromuscular control after anterior cruciate ligament (ACL) reconstruction. Several researchers including our group have shown that excessive tibial rotation is present in ACL deficiency. However, our research has demonstrated that even after ACL reconstruction, excessive rotation is still present in activities that are more demanding than walking and involve both anterior and rotational loading of the knee. These findings seem to persist regardless of the autograft selection for the ACL reconstruction. In addition, we have demonstrated that the scar tissue, which is developed in the donor site defect of the patellar tendon after harvesting the medial third, does not significantly alter the electromechanical delay (EMD) of the knee extensor muscles. On the contrary, a significant elongation of the EMD values of the hamstring muscles for the ACL reconstructed knee is observed when an ST/G graft is used. Therefore, our results suggested an impairment of neuromuscular control at the knee flexors after ACL reconstruction with an ST/G graft. In this review, our recommendations point towards further experimental work in order to assist in the identification of possible superiority between the two grafts and their usage.
Keywords
Anterior cruciate ligament reconstruction, gait analysis, tibial rotation, quadrupled hamstring autograft, bone–patellar tendon–bone autograft, electromechanical delay, isometric contractions
Disclosure The authors have no conflicts of interest to declare
Received: September 01, 2011 Accepted October 19, 2011
Correspondence: Anastasios D Georgoulis, Orthopaedic Sports Medicine Centre of Ioannina, PO BOX 1330, Ioannina 45110, Greece. E: georgoulis@osmci.gr

The anterior cruciate ligament (ACL) is critical for the normal functioning of the knee. Injury to the ACL can lead to functional impairment, meniscal lesions and early onset of joint degeneration. 1 It is estimated that approximately 250,000 ACL ruptures occur in the US every year;2 the majority of these injuries are sports related and affect individuals aged from 15 to 44 years. 3 It has also been found that approximately one ACL rupture will occur for every 1,500 player-hours spent practising or competing in sports such as football, skiing, basketball and soccer. 4 However, the orthopaedic surgeon contemplating the operative choice for ACL grafts and accompanying technique is confronted with a variety of choices.

With respect to the selection of the proper graft for ACL reconstruction, various choices have been proposed. Nowadays, the most commonly used grafts are the bone–patellar tendon–bone (BPTB) and the quadrupled hamstring tendons (semitendinous and gracilis; ST/G). In the past, the BPTB graft had been considered as the gold standard. However, in the early 1990s, use of the ST/G graft increased in popularity and has been advocated by many surgeons. This shift in popularity has occurred for several reasons, including concerns about damaging the knee extensor mechanism using the patella tendon procedure and the potential for subsequent anterior knee pain, patella fracture, ligament rupture and infra patella contraction. 5 In addition, the ST/G graft seems to be stronger and with a linear stiffness closer to the normal ACL than the BPTB. 6–8 However, potential complications also exist with the ST/G graft. Tunnel widening and fixation may be more of a problem in this procedure. There have also been concerns about how the graft harvest procedure may affect the muscle function of the hamstrings. Several clinical trials, 9–11 as well as reviews and meta-analyses, 12,13 have shown that neither graft is better than the other. Both grafts have advantages and disadvantages. This prohibits the publication of a general recommendation towards the orthopaedic society regarding the use of one graft or the other.

Our research group has hypothesised that this problem is the result of the absence of carefully designed in vivo experimental work to address this issue in detail. In the literature, there are very few kinematic studies 14 that have attempted to compare in vivo the two grafts. These studies examine mostly whether both grafts can affect gait patterns regarding the knee flexion–extension movement patterns. The other planes were not evaluated and specifically, the effect of graft type on tibial rotation was not assessed. However, evaluating tibial rotation is extremely important. This is because an in vitro study by Woo et al. 15 has shown recently that even though the two grafts can be successful in limiting anterior tibial translation, none of them is effective in reducing tibial rotation. Therefore, it is crucial to verify in vivo the above study and to compare the two grafts regarding their effectiveness in restoring tibial rotation under dynamic activities.

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Tibial Rotational Kinematics and Neuromuscular Control After Anterior Cruciate Ligament Reconstruction with the Bone–Patellar Tendon–Bone Autograft Versus Quadrupled Hamstrings

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