Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis

doi:10.1136/bmj.38784.384109.2F

BMJ 2006;332:995-1001 (29 April), doi:10.1136/bmj.38784.384109.2F (published 7 April 2006)

Research

Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis

David J Biau, specialist registrar (orthopaedic and trauma surgery)¹, Caroline Tournoux, specialist registrar (statistics and public health)², Sandrine Katsahian, consultant (statistics and public health)², Peter J Schranz, clinical director (orthopaedic and trauma surgery)⁴, Rémy S Nizard, professor (orthopaedic and trauma surgery)³

¹ Service de chirurgie orthopédique et traumatologique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75679 Paris, France, ² Département de biostatistique et informatique médicale, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 75475 Paris, ³ Service de chirurgie orthopédique et traumatologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, 75010 Paris, ⁴ Orthopaedics and Trauma, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter EX2 5DW

Correspondence to: D Biau djmbiau{at}yahoo.fr

Abstract

Objectives To compare bone-patellar tendon-bone autografts withhamstring autografts for reconstruction of the anterior cruciateligament.

Data sources Medline, WebSPIRS, Science Citation Index, CurrentContents databases, and Cochrane Central Register of ControlledTrials.

Review methods All randomised controlled trials reporting oneor more outcome related to stability (instrumented measurementof knee laxity, Lachman test, or pivot shift test) and morbidity(anterior knee pain, kneeling test, loss of extension, or graftfailure). Study quality was assessed by using a 5 point scale.Random effect models were used to pool the data. Heterogeneityin the effect of treatment was tested on the basis of studyquality, randomisation status, and number of tendon strandsused.

Results 24 trials of 18 cohorts (1512 patients) met the inclusioncriteria. Study quality was poor for nine studies and fair fornine studies. The weighted mean difference of the instrumentedmeasurement of knee laxity was 0.36 (95% confidence interval0.01 to 0.71; P = 0.04). Relative risk of a positive Lachmantest was 1.22 (1.01 to 1.47; P = 0.04), of anterior knee pain0.57 (0.44 to 0.74; P < 0.0001), of a positive kneeling test0.26 (0.14 to 0.48; P < 0.0001), and of loss of extension0.52 (0.34 to 0.80; P = 0.003). Other results were not significant.

Conclusion Morbidity was lower for hamstring autografts thanfor patellar tendon autografts. Evidence that patellar tendonautografts offer better stability was weak. The poor qualityof the studies calls into question the robustness of the analyses.

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Hamstring v patellar tendon autografts: A patient's and clinician's perspective: Sanjay Purkayastha
BMJ 2006 332: 1153. [Extract] [Full Text] [PDF]

Hamstring v patellar tendon autografts: When to operate is important: Peter Mrak
BMJ 2006 332: 1153. [Extract] [Full Text]

Hamstring v patellar tendon autografts: Author's reply: David J Biau
BMJ 2006 332: 1153. [Extract] [Full Text]

Hamstring autografts may be better than patellar tendon autografts
BMJ 2006 332: 0. [Full Text] [PDF]

Need for expertise based randomised controlled trials: P J Devereaux, Mohit Bhandari, Mike Clarke, Victor M Montori, Deborah J Cook, Salim Yusuf, David L Sackett, Claudio S Cinà, S D Walter, Brian Haynes, Holger J Schünemann, Geoffrey R Norman, and Gordon H Guyatt
BMJ 2005 330: 88. [Extract] [Full Text] [PDF]

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Lohmander, L. S., Englund, P. M., Dahl, L. L., Roos, E. M. (2007). The Long-term Consequence of Anterior Cruciate Ligament and Meniscus Injuries: Osteoarthritis. Am J Sports Med 35: 1756-1769 [Abstract] [Full text]
Poolman, R. W., Abouali, J. A.K., Conter, H. J., Bhandari, M. (2007). Overlapping Systematic Reviews of Anterior Cruciate Ligament Reconstruction Comparing Hamstring Autograft with Bone-Patellar Tendon-Bone Autograft: Why Are They Different?. JBJS 89: 1542-1552 [Abstract] [Full text]
Purkayastha, S. (2006). Hamstring v patellar tendon autografts: a patient's and clinician's perspective.. BMJ 332: 1153-1153 [Full text]
Mrak, P. (2006). Hamstring v patellar tendon autografts: when to operate is important.. BMJ 332: 1153-1153 [Full text]

Rapid Responses:

Read all Rapid Responses

Meta-analytical grafting: a patient's and clinician's perspective: Sanjay Purkayastha
bmj.com, 17 Apr 2006 [Full text]
Re: Meta-analytical grafting: a patient's and clinician's perspective: David J Biau
bmj.com, 20 Apr 2006 [Full text]
When to operate: peter mrak
bmj.com, 25 Apr 2006 [Full text]
conservative treatment and ACL tear: a need for more scientific evidence?: David J Biau
bmj.com, 26 Apr 2006 [Full text]
Need for an International Database & Use of Validated Scoring Systems: Turab A SYED
bmj.com, 2 May 2006 [Full text]
Patellar tendon vs Hamstring grafts for ACL reconstruction -which is better?: S THOMAS
bmj.com, 4 May 2006 [Full text]
Author's reply: David J Biau
bmj.com, 5 May 2006 [Full text]