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Second-Look Arthroscopic Evaluation and Clinical Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction with Autograft and Hybrid Graft: A Retrospective Study

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      Graft choice is very controversial. This study compared the second-look evaluation and clinical outcomes of anatomic ACL-R using a thin autograft versus a thick hybrid graft.


      Sixty-eight patients who had received ACL-R with hamstring autograft or autograft-allograft hybrid graft accepted second-look arthroscopy were grouped (autograft: n=31, age: 32.8±8.9, Male/Female: 16/15, and hybrid graft: n=37, age: 33.9±8.4, Male/Female: 27/10). Patients were evaluated with the functional score and KT-1000 test before reconstruction. The re-examination and second-look evaluation were performed at 2-year follow-up. Results were compared and further comparisons were made for grafts size >8.5 mm.


      The hybrid group showed thicker graft size and bigger graft occupancy (9.0±0.5 mm vs. 8.5±0.7 mm, P=.003; 80.1±7.0% vs. 69.9±6.9%, P<.001). KT-1000 test, subjective evaluation, and activity level scores increased significantly between pre- and post-reconstruction for both groups (P<.001). There was no significant difference of the second-look evaluation (Graft continuity, Tension and Synovial coverage) between groups. However, from those 2 groups, only grafts size >8.5 mm were selected and compared (autograft, n=16; hybrid, n=29). Graft tension and Synovial coverage showed a significant difference (P=.036 and P=.029). The Lysholm, IKDC, and KT-1000 test were significantly superior for the autograft than the hybrid graft (P=.036, P=.004, and P=.003, respectively).


      A pure autograft is superior to a hybrid graft with same diameter in ACL-R because the augmenting allografts may be null and void. Therefore, a homogenous graft is recommended.

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      Most cited references 43

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      Incidence and trends of anterior cruciate ligament reconstruction in the United States.

      Anterior cruciate ligament (ACL) injury is among the most commonly studied injuries in orthopaedics. The previously reported incidence of ACL injury in the United States has varied considerably and is often based on expert opinion or single insurance databases.
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        A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial.

        There are no controlled, prospective studies comparing the 10-year outcomes of anterior cruciate ligament (ACL) reconstruction using patellar tendon (PT) and 4-strand hamstring tendon (HT) autografts. Comparable results are possible with HT and PT autografts. Cohort study; Level of evidence, 2. One hundred eighty ACL-deficient knees that met inclusion criteria underwent ACL reconstruction (90 HT autograft, 90 PT autograft) by one surgeon and were treated with an accelerated rehabilitation program. All knees were observed in a prospective fashion with subjective, objective, and radiographic evaluation at 2, 5, 7, and 10-year intervals. At 10 years, there were no differences in graft rupture rates (7/90 PT vs. 12/90 HT, P = .24). There were 20 contralateral ACL ruptures in the PT group, compared with 9 in the HT group (P = .02). In all patients, graft rupture was associated with instrumented laxity >2 mm at 2 years (P = .001). Normal or near-normal function of the knee was reported in 97% of patients in both groups. In the PT group, harvest-site symptoms (P = .001) and kneeling pain (P = .01) were more common than in the HT group. More patients reported pain with strenuous activities in PT knees than in HT knees (P = .05). Radiographic osteoarthritis was more common in PT knees than the HT-reconstructed knees (P = .04). The difference, however, was composed of patients with mild osteoarthritis. Other predictors of radiographic osteoarthritis were <90% single-legged hop test at 1 year and the need for further knee surgery. An "ideal" outcome, defined as an overall International Knee Documentation Committee grade of A or B and a radiographic grade of A at 10 years after ACL reconstruction, was associated with <3 mm of instrumented laxity at 2 years, the absence of additional surgery in the knee, and HT grafts. It is possible to obtain excellent results with both HT and PT autografts. We recommend HT reconstructions to our patients because of decreased harvest-site symptoms and radiographic osteoarthritis.
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          Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods.

          A prospective randomized study was performed to determine the differences in results between three methods of anterior cruciate ligament reconstruction: autogenous bone-patellar tendon-bone graft (group 1), semitendinosus and gracilis tendon graft reconstruction combined with an extraarticular procedure (group 2), and semitendinosus and gracilis tendon graft reconstruction alone (group 3). Preoperatively, there were no significant differences between groups. At a mean of 35.4 +/- 11.6 months postoperatively, 102 patients returned for evaluation. International Knee Documentation Committee knee evaluation revealed no significant differences in symptoms, function, return to pre-injury activity, harvest site abnormalities, or limitation of motion between groups 1 and 3. Patients in group 2 had a higher incidence of patellofemoral crepitation and loss of motion than did patients in group 3. The mean manual maximum KT-1000 arthrometer side-to-side difference was 2.1 +/- 2.0 mm in group 1, which was statistically significantly better than the difference in group 3 (3.1 +/- 2.3 mm). Final knee rating showed that 34 of 35 patients in group 1, 23 of 34 patients in group 2, and 26 of 33 patients in group 3 had a normal or nearly normal overall knee rating. Anterior cruciate ligament reconstruction with a semitendinosus and gracilis or a patellar tendon autograft may yield similar subjective results; however, the patellar tendon autograft may provide better objective stability in the long term. In addition, there appears to be no benefit to combining an intraarticular anterior cruciate ligament reconstruction with an extraarticular procedure.

            Author and article information

            [1]Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China
            [2]Ri Zhao Hospital of Traditional Chinese Medicine (TCM), Rizhao, Shandong, P.R. China
            [3]People’s Hospital of Ri Zhao, Rizhao, Shandong, P.R. China
            Author notes
            Corresponding Author: Shijun Gao, e-mail:

            Study Design


            Data Collection


            Statistical Analysis


            Data Interpretation


            Manuscript Preparation


            Literature Search


            Funds Collection


            Hongtao Xu and Jiangtao Dong contributed equally to the study

            Med Sci Monit
            Med. Sci. Monit
            Medical Science Monitor
            Medical Science Monitor : International Medical Journal of Experimental and Clinical Research
            International Scientific Literature, Inc.
            23 November 2017
            : 23
            : 5564-5573
            © Med Sci Monit, 2017

            This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

            Clinical Research


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