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Asian Journal of Arthroscopy – Insights

Sachin Tapasvi, Parag Sancheti, Ashok Shyam

Volume 1 | Issue 1 | April – Jun 2016 | Page 42-44


Author: Sachin Tapasvi [1], Parag Sancheti [2] , Ashok Shyam [2],[3]

[1]  Orthopaedic Specialty Clinic, Pune Maharashtra.
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[3]  Indian Orthopaedic Research Group, Thane, India

Address of Correspondence

Dr Ashok Shyam
AJA Editorial Office, A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [w], Maharashtra, India.
Email: editor@asianarthroscopy.com


“Technique, Technique, Technique”, although Dr David Hungerford quoted the above for arthroplasty surgery, the same applies to Arthroscopy. Surgical technique and skill are unique to Arthroscopy almost as if it is a distinct area of expertise. No other subspecialty of orthopaedics has such minimal overlap with general orthopaedics, in terms of surgical techniques. One of the major goals of Asian Journal of Arthroscopy (AJA) is propagation of arthroscopy techniques. ‘Training by Publication’ is one the founding pillars of AJA. We want to bring the best techniques and procedures to our readers. These techniques will be in form of articles, pictograms and videos with basic premise of ease of learning. The readers should be able to understand the principles of the surgery, the critical steps and also learn new tips and tricks. They should be able to execute steps on the surgery and possibly embark on the learning curve to master the technique. Although more work is needed in terms of envisioning the formats of the article, this remains the mail goal of AJA and in times to come we would look for ways and means to do this more effectively. Currently the Journal has a technical note/video technique section with guidelines to submit a video article. We will also be running pictograms or Photo-articles which will be more pictures and less text (something like a comic strip but with much more smiles for arthroscopy surgeons!). ArthroMedia is a special section on the AJA website which will host multiple media items like videos, powerpoints, PDF and other documents related to surgical skills and surgeries. This will be compiled from contributions of editorial board, reviewers board, authors and also from our readers. This section will be open for submission to all and will compile the best training content. We invite all of you to submit your content to ArthoMedia and help us build this portal.

Why the new Journal when there are already existing journals of Arthroscopy?
There are two main reasons; to produce a body of literature that is clinically relevant and to make this knowledge freely accessible to all. Journals have shown trend to move towards a more rigid framework of scientific publications, meanwhile losing the mail focus of scientific publications. Journals are meant to directly influence and improve patient care. Charging for downloading articles imposes another limitation on dispersion and use of knowledge. AJA intends to counter these two issues by creating a journal that is intelligent, interactive, and clinically relevant and at the same time completely Open Access. The entire format of the Journal will be one of ‘Integration’ with basic science, molecular research, clinical trials, clinical research, case based discussion, evidence based medicine, expert opinion and patients perspective, all aiming together to ‘Translate’ into betterment of Arthroscopy strategies and surgeries. Although the Journal will focus on Asian studies, it will be open to submissions from all across the globe.
The Journal will be open access, peer reviewed and will have three issues every year. It will be published in both online and print formats. The Journal is the official Arthroscopy Journal of the Orthopaedic Research Group. The Research Group has affiliation to Ebscohost and is a member of Crossref. Thus primarily the journal will be indexed with Ebscohost and will have a doi (digital object identifier) for each article. Within due course we aim to index the journal with all major indexes including Pubmed and Science citation index.

What is unique about AJA?
The most important unique point of AJA is that it is a Surgeon Initiated Journal. The entire concept of the journal, the designing of website, manuscript portal and guidelines are all made by a team of surgeons. The team will be self-publishing the Journal and there will be no external publisher involved. All the rights of the journal is with the editorial board and the core team of AJA and no rights belong to any external body. This gives us a lot of flexibility and helps the journal to adapt rapidly to changing needs of the readers and authors. The journal decisions can be taken rapidly and since the entire process is controlled by the AJA team, the quality of peer review and content will be excellent. With no constraint of a corporate publisher, we can lay down our own rules and regulations and provide best of services to the Arthroscopy community
We believe AJA is an ambitious project and has much potential to evolve along with the evolution of Arthroscopy Surgery. We have great plans for AJA and we hope for great co-operation from the Arthroscopy community. Please do send your suggestions, opinions and comments to us at the editorial email. AJA is a journal “By the Surgeon, for the Surgeon, and of the Surgeon” and together we can take it to great heights

Dr Sachin Tapsvi | Dr Parag Sancheti | Dr Ashok Shyam


How to Cite this article: Tapasvi S, Sancheti PK, Shyam AK. Asian Journal of Arthroscopy – Insights. Asian Journal of Arthroscopy  Apr- June 2016;1(1):1-2

Dr. Sachin Tapasvi

Dr. Sachin Tapasvi

Dr. Parag Sancheti

Dr. Parag Sancheti

Dr. Ashok Shyam

Dr. Ashok Shyam


(Abstract)      (Full Text HTML)      (Download PDF)


Intraoperative Graft Contamination – What Options Do We Have?

Parag Sancheti, Sachin R Jain, Ashok Shyam

Volume 1 | Issue 1 | April – Jun 2016 | Page 35-37


Author: Parag Sancheti [1], Sachin R Jain [1], Ashok Shyam [1],[2]

[1] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[2] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence

Dr Parag Sancheti
Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
Email: parag@sanchetihospital.com


Abstract

Background: Accidental graft contamination is not uncommon in a high volume centers practicing ligament reconstruction surgeries. There are several techniques of disinfecting the graft to prevent septic arthritis postoperatively. Aim of this review is to identify the different options of appropriate disinfectant and also the time interval for immersing the graft in the disinfectant solution for contaminated ACL graft.
Material and methods: MEDLINE, Pubmed and extensive searches of major arthroscopy journals identified several studies regarding graft contamination and its disinfection protocol which was used in this study.
Conclusion: 4% chlorhexidine or 10 % povidone iodine seem to be most effective in disinfecting contaminated graft after immersion for 3 min and 15 min respectively. All sutures should be removed prior to disinfection and proper antibiotic cover and follow up should be done to prevent any residual infection.
Keywords: Anterior cruciate ligament reconstruction, graft contamination, antiseptics


Introduction

Anterior Cruciate Ligament (ACL) reconstruction is the most common ligament reconstruction surgery done in the world(1). There is always a possibility of inadvertent graft contamination by dropping it accidentally on floor(2). 25% of fellows in sports medicine report at least one such event(3). Various treatment modalities exist to prevent postoperative infection due to contaminated graft such as cleansing alone with normal saline, immersion in 4 % chlorhexidine and bacitracin solution, 10% povidone – iodine solution, sodium hypochlorite solution or antibiotic solution wash (2,3,4,5). Other option is to discard the graft and harvest another graft or use an allograft, but this causes donor site morbidity or increased cost associated with use of allograft(3). Floor cultures can be simultaneously obtained to find out the organism grown during contamination.

Methods

MEDLINE, Pubmed and extensive searches of major arthroscopy journals identified several studies regarding graft contamination and its disinfection protocol which was used in this study. Aim of this review was to find out the epidemiology of graft contamination, different agents used for decontaminating the graft and its efficacy, organism grown in floor or contaminated graft culture, cleaning protocol for hamstring graft and for bone patellar bone tendon graft, preventing measures for graft contamination and finally treatment with antibiotic protocol postoperatively.

Discussion

Around 25% surgeons have reported to have a contaminated graft at least once with 35% of these surgeons performing at least 100 ACL surgeries annually (1). Sterilization by autoclaving destroys the material properties of collagenous tissue, so other sources of nondestructive disinfection must be considered (9).

Barbier et al(2) compared 4 groups after dropping graft on the floor with cultures taken after immersion in antiseptic solution for 15 min – 4 % chlorhexidine gluconate solution (group 1),  10% povidone–iodine solution (group 2), sodium hypochlorite solution (group 3) and (group 0) was cultured without being exposed to any solution. They found that floor swab cultures were positive in 96% of cases and rate of contamination was 40% in group 0, 8% in group 1, 4% in group 2, and 16% in group 3. There was a significant difference between groups 1 and 2 and group 0 (p < 0.05) but not between groups 3 and 0. They concluded both 4% chlorhexidine as well as povidone iodine solutions are effective in treatment of contaminated graft. Sodium hypochlorite is not so effective with this respect. Molina et al.(8) found that 58% of the dropped grafts had positive cultures and also, 4 % chlorhexidine and double antibiotic solution (neomycin and polymyxin B) successfully decontaminated dropped native ACLs at a rate of 98 and 94 %, respectively. The time duration used by different surgeon varies for different surgeons which ranges from 90 seconds to 30 minutes(1). The most common antiseptic solution chosen by the high volume surgeons was chlorhexidine(1). However, when povidone– iodine solution was used, 24 % of the ACL graft had resulted in positive cultures. Graft can be washed for a period 3 min to reduce undue delay of the surgery(3). Their limitation was that the graft was kept in the sterilizing agent for 90sec and then sent for culture. Pasque et al(10) suggested getting the graft off of the floor immediately, removing any suture material in the graft, cleansing the graft for 15 to 30 minutes each in chlorhexidine and triple antibiotic solution, followed by a normal saline rinse is associated with very less chance of infection. Casalonga et al. (11) followed the outcome of four patients in whom the B-T-B graft dropped onto the floor was re-implanted after decontamination with topic antibiotics. The grafts were soaked in rifamycin and then gentamycin for 10 min each along with postoperative antibiotics for 15 days. There were no complications or postoperative infections, and all patients were able to return to previous sport level. Cooper et al (12) after soaking contaminated grafts in antibiotic solution for 15 min suggested it may reduce the incidence of positive cultures but it may still result in a 30% incidence of nonsterile grafts. Floor cultures most commonly grow coagulase-negative Staphylococcus, bacillus species and diphtheroids(13, 3). The limitation of this study that it was done in cadavers. Plante et al (3) suggested that immediate graft retrieval (<5 sec) did not affect the rate of contamination when compared to fifteen-second exposure (33 vs. 23 %). Sobel et al(14) suggested that structural properties of human patellar tendon allografts are not significantly affected by soaking in 4% chlorhexidine gluconate for 30 minutes. Stanwood et al(1) stated that 71% of surgeons who experienced graft contamination cleansed the graft, and 75% contaminated grafts were cleansed and the ACL reconstruction proceeded as planned. In 18% an alternative autologous graft of contralateral patellar tendon or ipsilateral hamstrings was used to replace the contaminated graft and in 7% of cases, an allograft was used.

In general, the rate of contamination of graft if dropped on floor is between 63 to 96 % and the contaminant grown in culture is staphylococcus(12,8,10, 2). Also, the time interval of dropping the graft and its retrieval doesn’t influence the culture as the different studies have compared the different time interval i.e. 15 sec,  3 min which found similar growth(2). This suggests a definite need of treatment of graft after contamination irrespective of the time duration. Chlorhexidine and povidone iodine solutions both are broad spectrum antiseptics and chlorhexidine is activated in less than 1 min and 10% povidone-iodine takes a longer time to activate with increased activity after 5 min(2). This suggested the need of different immersion time required to disinfect the graft in different solution, in 4 % chlorhexidine solution 3 min may be adequate(8) whereas it may require upto 15min  immersion in 10% povidone-iodine solution(2). Soaking of grafts in antibiotic solutions might increase the risk of multiresistant organism being selected(2) also there is 30% risk of getting non sterile graft(12). If a sutured hamstring graft is contaminated then all the sutures are to be removed before immersion in a disinfectant solution(2).

Jones et al(15) studied the mechanical properties patellar tendon allograft subjected to chemical sterilization(BioCleanse) and found that preimplantation mechanical properties of BPTB allografts treated with BioCleanse are not significantly different from those of untreated controls.

Other than dropping of graft on floor, graft contamination during surgery may occur at various steps of surgery before implantation. Hantes et al (6) studied various sources of contamination of hamstring and patellar tendon autograft. Three tissue samples were obtained for culture from each graft at different time-intervals during graft preparation process, during graft preparation completion and during graft implantation. In addition, the erythrocyte sedimentation rate and the C-reactive protein level were evaluated preoperatively and on the third, seventh, and twentieth postoperative days. Authors concluded that a high rate (12%) of autograft contamination can be expected during autograft preparation for anterior cruciate ligament reconstruction. The contamination rate is almost equal for both bone-patellar tendon-bone and hamstring tendon autografts which was confirmed with normal ESR and CRP reports. However, there was no evidence of postoperative infection with intraoperative contamination results in their series. They further suggested that no excessive antibiotic is required for positive cultures and no evidence of clinical signs of infection. Postimplantation of the contaminated graft after disinfection, it is advised to treat the patient with IV antibiotics and/or oral antibiotics for 1 or 2 weeks. Also, a close watch to be kept until 6 weeks of surgery ifany signs of infection develops(10).

There is a very high chance of contamination of graft when a new staff is given the responsibility of holding graft or surgeon goes to a new setup(10). To prevent this, surgeon should personally get the graft from the time of harvest till getting it on the preparation table. Similarly, new staff or resident who is preparing the graft should be adequately trained and strictly monitored to prevent dropping of graft. Finally all the OR personnel should realize the importance of surgery and be careful at all times especially while transfer of graft from preparation table to implantation site and vice versa.


Conclusion

4% Chlorhexidine with or without bacitracin is the best solution for disinfection of contaminated graft. Graft has to be minimum kept for 3 min immersed in the solution for proper disinfection. If 10% povidone-iodine is to be used graft has to be immersed at least 15 minutes. Earlier the retrieval of graft, better the disinfection as shown comparison between less than 5 second retrieval and 15 sec graft retrieval from floor. All suture material must be removed while disinfecting the graft. Post implantation, antibiotics have to be given for a period of 1 or 2 weeks and have to be followed for at least 6 weeks


References

  1. Stanwood W, Levine WN, Ahmad CS. A Survey of Sports Medicine Specialists Investigating the Ligament Grafts. 2005;21(11):1348–53.
  1. Barbier O, Danis J, Versier G, Ollat D. The Knee When the tendon autograft is dropped accidently on the fl oor : A study about bacterial contamination and antiseptic ef fi cacy. Knee [Internet]. Elsevier B.V.; 2016;22(5):380–3. Available from: http://dx.doi.org/10.1016/j.knee.2014.07.027
  1. Plante MJ, Li X, Brown MA, Busconi D, Deangelis NA. Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction. 2013;21(3):696–701.
  1. McAllister DR, Parker RD, Cooper AE, Recht MP AJ. Outcomes of post-operative septic arthritis after anterior cruciate ligament reconstruction. Am J Sport Med. 1999;27:562–70.
  1. Schollin-Borg M M elsson, Micha¨ elsson K RH. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy. 2003;19:941–7.
  1. Me H, Gk B, Se V, Giotikas D, Petinaki E, Kn M. Autograft Contamination During Preparation for. 2008;760–4.
  1. Stanford R, Solomon M, Levick M, Kohan L, Bell S. Sterilization of Contaminated Bone-Tendon Autografts Using 10% Povidone-Iodine Solution. Orthopedics. 1999;22:601–4.
  1. Molina ME, Nonweiller DE, Evans JA, Delee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000 May-Jun;16(4):373-8.
  1. Davis KW, Stauderman WE, Mayfield J WJ. Gamma radiation dose setting and auditing strategies for sterilization of medical devices. In: Gaughran ERL, Morri-of medical products. Montreal. Steriliz Multiscience Publ Ltd. 1981; Vol 2:34-102
  1. Pasque C, Geib T. Intraoperative Anterior Cruciate Ligament Graft Contamination. 2016;23(3):329–31.
  1. Casalonga D, Ait Si Selmi T RA et al. Peroperative accidental contamination of bone-tendon-bone graft for the reconstruction of the anterior cruciate ligament. Report of 4 cases. Rev Chir Orthop Reparatrice Appar Mot. 1999;85(7):740–3.
  1. Cooper DE, Arnoczky SP, Warren RF. Contaminated Patellar Tendon Grafts : Incidence of Positive Cultures and Efficacy of an Antibiotic Solution Soak-An In Vitro Study. 1991;272–4.
  1. Richard D. Parker, Evan J. Bachner, Michael J. Dul, Dirk Treleven, Matthew E. Levy and PP. The Scientific Basis for the Management of Contam- inated Bone-Tendon Grafts: The Serial Dilution/ Mechanical Agitation Technique. Arthroscopy. 1993;9(3):354.
  1. Sobel AD, Hohman D, Jones J, Bisson LJ. Structural Properties of Human Patellar Tendon Allografts. YJARS [Internet]. Elsevier Inc.; 2016;28(12):1862–6.
  1. Jones DB, Huddleston PM, Zobitz ME, Stuart MJ. Mechanical Properties of Patellar Tendon Allografts Subjected. 2007;23(4):400–4.

How to Cite this article:. Sancheti P, Jain SR, Shyam AK. Intraoperative Graft Contamination – What Options Do We Have? Asian Journal of Arthroscopy  Apr- June 2016;1(1):35-37 .

Dr. Parag Sancheti

Dr. Parag Sancheti

Dr. Sachin Jain

Dr. Sachin Jain

Dr. Ashok Shyam

Dr. Ashok Shyam

 


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BTB Vs Hamsrtings – Is There a Winner Yet ?

Sachin Tapasvi, Sachin Jain, Ashok Shyam

Volume 1 | Issue 1 | April – Jun 2016 | Page 11-15


Author: Sachin Tapasvi [1 ], Sachin Jain [2], Ashok Shyam [2],[3]

[1] Orthopaedic Specialty Clinic, Pune, Maharashtra. India
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[3] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence

Dr Sachin Tapasvi
Orthopaedic Specialty Clinic, Pune Maharashtra. India.
Email: stapasvi@gmail.com


Abstract

Bone patella tendon bone (BPTB) graft versus Hamstring (HT) Graft is still an issue that is debated. Both the graft have stood the test of time with high patient satisfaction however each have their own advantages and disadvantages. BPTB has advantages of good stability and bone to bone healing and disadvantage of anterior knee pain, numbness and quadriceps weakness. HT graft have advantage of less donor site morbidity, less extension deficit and disadvantage of having a slightly higher failure rate and hamstring weakness. Irrespective of these named advantages and disadvantages the patient reported outcomes are similar with both graft and difference in choice of graft is poorly understood. In this review we simply try to bring our reader up-to-date with the current literature on this controversy
Keywords: Bone patella tendon bone graft, hamstring graft, anterior cruciate ligament reconstruction.


Introduction

Anterior cruciate ligament (ACL) is required for static and dynamic stabiliser of the knee joint and purpose of ACL reconstruction is to stabilize and to resume function to maximum extent (1, 2). The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity (3). Moreover, these properties should be present at the time of graft implantation and persist throughout the incorporation period too (3).
Graft options available are broadly grouped into autograft such as bone patellar bone tendon graft (BPTB), hamstring graft, Quadriceps graft and allograft such quadriceps, patellar, Achilles, hamstring, and anterior and posterior tibialis tendon graft (3-6). Allografts are useful to minimize donor site morbidity but are associated with increased cost, slower incorporation time, increased risk of disease transmission, and a higher failure rate (2). The synthetic grafts are yet to prove themselves and currently the most commonly used graft used for ACL reconstruction are autografts namely hamstring or BPTB graft. With BPTB graft comes with advantages of excellent initial fixation, biomechanical properties, durability, success at long- term follow-up with reduced pivot shift test (7, 8) and disadvantage of few reports suggesting donor site morbidity of patellofemoral osteoarthritis, scar formation with shortening of the patellar tendon, loss of terminal knee extension, and patellofemoral pain(2,9,10).
Semitendinosus and gracilis tendons (quadrupled hamstring tendon [HT]) have found to minimize donor site morbidity causing less anterior pain(8) with disadvantage of numbness of the anterior knee caused by injury to the infrapatellar branch of the saphenous nerve during graft harvest(2), longer rehabilitation period(3,10) and persisting pivot shift test at long term follow up(7). There are multiple extrinsic and intrinsic confounding variables(11) while studying the results of ACL reconstruction out of which isolated effects of a single extrinsic variable of graft choice is to be made.

Method of Review
There are several review articles published in literature including Pubmed, Medline and Cochrane database to compare of graft superiority (hamstring versus BPTB) in ACL reconstruction. We primarily did a pubmed search with Bone-Patellar Tendon-Bone Grafting as the Mesh major keyword. Two hundred and eighty five article were found and reviewed. There were 51 articles that either compared the two grafts or were meta-analysis of such articles. These 51 articles were then further reviewed to construct this review. There were 9 metanalysis among these 51 articles and 3 additional systematic reviews (1,4,7, 11-20). The Cochrane review of 2011 and a systematic summary of systematic reviews was also added to this list (21,22). Results of all these reviews were compiled and presented in Table 1. Other relevant articles were added to the review depending on the significance of their findings. It was noted that in most article the main areas of comparison between the two grafts were stability, donor site morbidity, complications, rehabilitation status, functional outcomes and revision rates due to graft. The present review is also arranged in this format.

Functional outcome
Functional outcome was measured in most of the articles using scores like Lysholm knee score, Tegner activity level, International Knee Documentation Committee (IKDC) scores etc. None of the studies found any difference in functional outcome measured (1,4,7,11-19,23-25) and hence both the grafts are equally effective in terms of restoring the functional ability of the patients. Pinczewski et al noted that Level 1 and 2 sports activities were significantly reduced from 73 to 85% (short term) to 45-57% (long term results) in both HT and BTPB groups (11). Recent review mentions that patients with HT graft are almost twice more likely to return to sports but patient with BPTB Graft are more likely to return or exceed the preoperative sports level (22). Other also indicate that patients with BPTB graft return to activity earlier than the HT graft (12). This may be probably because BPTB graft provide more static and rotational stability (1,15). Poolman et al (17) commented that modern techniques of HT graft will further increase stability and improve return to activity. However this is not confirmed by recent articles and possibly better controlled trials will be needed to eventually answer the question.

Donor site morbidity and complication after graft harvesting
When overall incidence of morbidity was reviewed, HT graft patient have lower incidence of morbidity (12,15). Anterior knee pain and kneeling pain was significant in BTPB group as compared with HT group(1–3,11,23). Anterior knee pain is related to the secondary chondromalacia patella which happens after ACL reconstruction regardless of graft type but it is noted that it can be five times greater in BPTB group versus HT group(2). There was a significant extension loss of >5 degrees in BPTB group versus HT group(1). It is noted that there was a concentric and eccentric reduction in Quadriceps power which was related to poor satisfaction rates (23). The Cochrane review in 2011 noted that BPTB Graft resulted in loss of knee extension range and strength while HT graft showed trend toward loss of flexion range and strength (21). There was a slight risk of patellar fracture which was mainly related to the errors in the surgical technique or use of unnecessary deeper saw cuts or osteotomes(23). Other donor site problems noted are patellar tendinitis, rupture of patellar tendon, increased joint stiffness, late chondromalacia and injury to infrapatellar branch of saphenous nerve(2,3,23). Reduced ultimate range of motion may be related to the rigid construct used in fixing BPTB graft (2). Other disadvantage of hamstring graft are injury to the superficial branch saphenous nerve and weakness of the hamstring muscles after operation (23, 24).

Stability
Stability has shown varied results in different studies and possible is a function of surgical technique and rehabilitation [Table 1].

Table 1: Comparative analysis of meta-analysis comparing BPTB and HT autograft

Table 1: Comparative analysis of meta-analysis comparing BPTB and HT autograft

Stability was assessed by Lachman test, pivot shift test and KT -1000 arthrometer in most series. Some authors reported no significant difference between either HT or BPTB group at long term follow up (11, 2). However, in mid-term follow up the side-to-side instrumented laxity (>2 mm) was greater in HT group as compared to BPTB group (7). BTPB is also found to be more rotationally stable with respect to pivot shift test (1).
Stability in case of HT graft was based on the number of strands used during surgery when compared with BPTB graft (1). When a 2 strand HT graft was used a statistical difference was noted in case of KT – 1000 and pivot shift test in favour of BPTB graft whereas Lachman test was not significant in both groups. If a 4 strand HT graft with a suspensory fixation like endobutton was used then the statistical difference was not significant in both the groups and had near normal Lachman, pivot shift tests and KT – 1000 testing(1,10,26–28). There is a slightly higher degrees of laxity noted in quadrupled hamstring graft as compared with BPTB graft especially in females in long term studies(2,20). Cochrane review noted that BPTB reconstructions are more likely to result in statically stable knees but they are also associated with more anterior knee problems. However there is insufficient evidence to predict superiority of one graft over other in long results in respect to functional outcome(21). In a study, comparing double bundle reconstruction with HT graft and anatomical BPTB graft positioning equal results are found with respect to stability and laxity throughout the range of motion(29). The recent summary of meta-analysis however concluded that BPTB graft are more stable as per the current available evidence (22)

Rehabilitation
It is noted that integration of bone to bone healing with direct insertion is much faster in BPTB graft as compared to bone to soft tissue healing by means of indirect insertions with sharpey’s fibres in case of HT graft(23). So with rapid incorporation with graft healing to bone, there is potential for accelerated rehabilitation in BPTB graft and may be earlier return to play sports activities(3,23). It usually takes 6 weeks for a BPTB to incorporate in the host bone whereas around 8 to 12 weeks with HT graft(3). Short term studies showed mixed results of quadriceps strength with HT graft harvest whereas long term studies shows no difference in quadriceps strength with BPTB versus HT graft(8,20). Evaluation of functional capacities: power, strength, velocity and dynamic stability of knee extensor and flexor muscles after ACL reconstruction showed that use of a BPTB autograft achieved better muscular and functional capacities than the HT autograft(6). During rehabilitation with hamstring graft requires less supervision with less risk of complications such as the infrapatellar contracture syndrome, arthrofibrosis or persisting pain(23).

Osteoarthritis Risk
Radiographic assessment showed no significant differences between the two groups in terms of osteoarthritic findings classified according to the Fairbank and Ahlback rating systems in short term studies(26) and mild osteoarthritic changes in BPTB group at mid and long term follow up as compared with HT group(11). Overall, osteoarthritis was identified in 16% (BPTB 19%; ST 13%.) according to the Ahlback rating system and 68% (BPTB 67%; ST 70%; ) according to the Fairbank rating system(26). Xie et al found the risk of development of OA was around 61% greater in BPTB graft as compared to HT Graft (14). Early osteoarthritic changes are also function of primary injury and associated injuries like meniscal injuries and cartilage injuries (30). However late onset osteoarthritis will require much longer follow up and none of the current studies offer much insight into development of OA in long term (22)

Failure rates
There is no obvious difference in the occurrence of ligament failure between HT group and the BPTB group after ACL reconstruction in long term studies but a few studies demonstrate reduced failure rates with BPTB graft(1). Hamstring graft harvest weakens the knee flexor strength leading to slightly higher degrees of graft failure (2,4). However, these studies had a selection bias which had included studies using double or triple strand graft which gave slightly higher failure rates. Long term studies have shown to have equal success rates with quadrupled hamstring graft or BPTB graft(8,20). Moreover, it is also noted that the fixation modality and anatomical placement of ACL is responsible for low failure rates(20) It has been noted that contralateral ACL tear with BPTB graft is statistically significant as compared to HT graft in short term studies whereas in long term studies there is no increase in contralateral ACL tear(8). A risk factor for contralateral ACL rupture was a return to sports that involved sidestepping, pivoting, and jumping (8). In a registry study based on 45,998 primary ACL Reconstructions in Scandinavi it was found that patients receiving patellar tendon autografts have a statistically significantly lower risk of revision compared with patients receiving hamstring autografts(5).


Conclusions

As per current reviews and evidence, both graft achieve good functional outcome in patients. BPTB graft may offer a more stable knee and possible achieve rapid and effective return to preinjury activity level. HT graft have less donor site morbidity and with new effective fixation modalities, they may also match the stability achieved by BPTB grafts. However there is insufficient evidence to clearly establish a winner and probably more robust future studies will be better able to define the role of each of these autograft options


References

1. Li S, Su W, Zhao J, Xu Y, Bo Z, Ding X, et al. Review A meta-analysis of hamstring autografts versus bone – patellar tendon – bone autografts for reconstruction of the anterior cruciate ligament. Knee 2011;18(5):287–93.
2. Shelton WR, Fagan BC. Autografts Commonly Used in Anterior Cruciate Ligament. J Am Acad Orthop Surg. 2011;19(5):259–64.
3. West R V, Harner CD. Graft Selection in Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2005;13(3):197–207.
4. Reinhardt KR, Hetsroni I. Graft Selection for Anterior Cruciate Ligament Reconstruction : A Level I Systematic Review Comparing Failure Rates and Functional Outcomes. Orthop Clin NA [Internet]. Elsevier Ltd; 2010;41(2):249–62.
5. Gifstad T, Foss OA, Engebretsen L, Lind M, Forssblad M, Albrektsen G. Lower Risk of Revision With Patellar Tendon Autografts Compared With Hamstring Autografts A Registry Study Based on 45 , 998 Primary ACL Reconstructions in Scandinavia. Am J Sports Med. 2014;42(10):2319–28.
6. Baur C, Mathieu N, Delamorclaz S, Hilfiker R, Blatter S, Siegrist O, et al. Anterior cruciate ligament reconstruction : Hamstring Tendon autograft versus Bone Patellar Tendon Bone autograft : what about muscular and functional capacities ? Schweizerische Zeitschrift für Sport und Sport. 2015;63(2):18–22.
7. Biau DJ, Katsahian S, Kartus J, Harilainen A, Feller JA, Sajovic M, et al. Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament : A Meta-Analysis Based on Individual Patient Data. Am J Sports Med. 2009;37(12):2470–8.
8. Macaulay AA, Perfetti DC, Levine WN, Macaulay AA, Perfetti DC, Levine WN. Anterior Cruciate Ligament Graft Choices. Sport Heal A Multidiscip Approach. 2012;4(1).
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How to Cite this article:. Tapasvi S, Jain S, Shyam AK. BTB Vs Hamsrtings – Is There a Winner Yet ?. Asian Journal of Arthroscopy  Apr-June 2016;1(1):11-15 .

 

Dr. Sachin Tapasvi

Dr. Sachin Tapasvi

Dr. Sachin Jain

Dr. Sachin Jain

Dr. Ashok Shyam

Dr. Ashok Shyam


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