Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 4, pp 1281–1287 | Cite as

Hamstring autograft maturation is superior to tibialis allograft following anatomic single-bundle anterior cruciate ligament reconstruction

  • Sang-Gyun Kim
  • Soo-Hyun Kim
  • Jae-Gyoon Kim
  • Ki-Mo Jang
  • Hong-Chul Lim
  • Ji-Hoon Bae
Knee
  • 248 Downloads

Abstract

Purpose

Using second-look arthroscopy, graft maturation was investigated and compared between hamstring (HA) autografts and tibialis anterior (TA) allografts after anatomic single-bundle anterior cruciate ligament reconstruction (ACLR).

Methods

Fifty-six patients who underwent second-look arthroscopy after anatomic single-bundle ACLR with either HA autografts (26, HA group) or TA allografts (30, TA group) from 2007 to 2016 were retrospectively reviewed. Graft maturation on second-look arthroscopy was evaluated in terms of four parameters: graft integrity (tear), synovial coverage, graft tension, and graft vascularization. Each parameter received a maximum of two points, depending on the status of the reconstructed graft. The total graft maturation score was calculated as the sum of the parameter scores. The total graft maturation and individual parameter scores were compared between the two groups.

Results

The mean time from ACLR to second-look arthroscopy was 22.5 ± 7.8 months. The maturation scores in the HA group were significantly better in terms of graft integrity (p = 0.041), graft tension (p = 0.010), and graft vascularization (p = 0.024), whereas the graft synovial coverage score was not significantly different. The total graft maturation score of the HA group was significantly higher than that of the TA group (6.3 ± 0.4 vs. 4.9 ± 0.3, p = 0.013).

Conclusions

This study shows the superior graft maturation of HA autografts compared with that of TA allografts at a mean follow-up of 22.5 ± 7.8 months after anatomic single-bundle ACLR. When anatomic ACLR using soft tissue graft is planned, HA autograft is recommended rather than soft tissue allograft, especially in young and active patients.

Level of evidence

Retrospective cohort review, Level III.

Keywords

Anterior cruciate ligament reconstruction Hamstring Tibialis anterior Second-look surgery Arthroscopy 

Introduction

Allografts have been shown to be a good alternative to autografts in anterior cruciate ligament (ACL) reconstruction (ACLR) [8, 20, 24]. The advantages of allograft tissue are the lack of donor-site morbidity, shorter operative time, improved cosmesis, and multiple graft options and sizes [2, 12, 14, 16]. The risks associated with allogeneic tissue include potential disease transmission, delayed incorporation, and decreased graft strength and stiffness, depending on the processing technique that is used [9, 15, 25, 26]. The argument as to the superiority of one type of graft over the other in ACLR remains unsettled.

ACL grafts undergo the process of ligamentization, which is the continuous remodelling and development of the intra-articular graft tissue into a ligament-like structure similar to a native ACL [6, 10, 27]. Several studies have reported the histologic changes during the ligamentization process in human autografts [1, 10, 27, 32, 33]. However, the histologic findings of ligamentization of autografts and allografts have only been compared in animal studies [9, 15, 26, 28]. Since the biopsy procedure has the risk of damaging the reconstructed graft, it is difficult to conduct such investigations. Second-look arthroscopy offers a less invasive method to evaluate and compare the graft healing process according to the graft type, although it cannot reveal histologic differences.

A recent study reported that the failure rate for soft tissue allografts is three times higher than that for HA autografts, at a minimum of 10 years after single-bundle ACLR [7]. This may be because of the different graft ligamentization potential between autografts and allografts. Recently, Yoo et al. [31] compared the tears and synovial coverage of grafts by using second-look arthroscopy. They reported that hamstring (HA) autografts showed considerably better synovial coverage than tibialis anterior (TA) allografts, although the clinical outcomes were not different between the grafts. This result has provided an important clue; however, it seems insufficient to explain the higher failure rate of allografts.

Recently, a higher incidence of unfavourable graft maturation has been observed after anatomic single-bundle ACLR using TA allografts compared to HA autografts. Despite the similar short-term clinical outcomes between autografts and allografts, the quality of graft ligamentization can directly impact long-term survival [7, 8]. However, there are few published studies comparing the quality of graft ligamentization related to graft types [21, 31]. In this study, graft maturation was investigated and compared between HA autografts and TA allografts after anatomic single-bundle ACLR by using second-look arthroscopy. For the objective evaluation, a graft maturation scoring system was developed based on previous studies [3, 4, 19, 30, 31]. It was hypothesized that the graft maturation of HA autografts would be superior to that of TA allografts according to second-look arthroscopic findings.

Materials and methods

Patients who underwent second-look arthroscopy after anatomic single-bundle ACLR between 2007 and 2016 were retrospectively reviewed. The operation was performed at three institutions by six surgeons. The inclusion criteria were as follows: (1) primary single-bundle ACLR, (2) ACLR with HA autograft or TA allograft, (3) preparation of femoral tunnel with the anatomic ACLR technique (outside-in technique or transportal technique), and (4) the same fixation technique (cortical suspensory device on the femoral side and a bioabsorbable interference screw with a backup screw fixation on the tibial side). The exclusion criteria were as follows: (1) concomitant ipsilateral fracture around knee; (2) multi-ligament injury; (3) revision ACLR; (4) early graft failure due to postoperative infection, fixation failure, tunnel malposition, and other factors; and (5) re-injury during the follow-up period (before second-look arthroscopy).

Surgical technique of ACLR and postoperative rehabilitation

ACLR was completed using the following approach. Diagnostic arthroscopic examination was performed to identify the status of the ACL, menisci, and cartilage injury. When combined meniscus injury was observed, meniscectomy or meniscus repair was performed before ACL reconstruction. All ACL reconstructions followed a similar procedure: removal of the torn ACL, graft harvest and preparation (HA group), femoral tunnel preparation (centre of footprint) with transportal or outside-in technique, tibial tunnel preparation (45°–50° angle, centre of footprint), graft passage, femoral tunnel fixation, cyclic loading applied 20 times, graft tensioning in full knee extension, tibial tunnel fixation with a bioabsorbable interference screw and a 6.5-mm cancellous screw with a spike washer, and wound closure. In the HA group, the gracilis and the semitendinosus tendons were harvested and prepared as a quadruple autograft. The proximal loop side of the graft was prepared by using suspensory devices (ENDOBUTTON [Smith & Nephew, Andover, MA, USA] or TightRope [Arthrex, Naples, FL, USA]). The distal end of the graft was prepared with a running (baseball) suture. In the TA group, the fresh-frozen TA tendon was prepared as a two-strand graft. Both ends of the graft were prepared with the same manoeuvre used in the preparation of the hamstring autograft. The graft diameters ranged from 8 to 9 mm in both groups.

After ACLR, the same rehabilitation protocol was applied to all patients. Range-of-motion and isometric quadriceps exercises were started 1–2 days after surgery and were continued. Gait training, balance exercises, and proprioceptive exercises were started 3–4 weeks postoperatively. Partial weight bearing crutch gait was permitted postoperatively. Full weight bearing was allowed 6–8 weeks after surgery. Running, plyometric exercises, agility exercises, and sports-specific exercises were started 3–4 months after surgery. Return to previous sports activities was allowed 9–12 months after surgery, if the patient had achieved >80% muscle strength compared with the contralateral uninjured leg.

Second-look arthroscopy and graft evaluation method

The medical records, stress radiographs, videos, and pictures taken during the second-look arthroscopic examination were reviewed. Second-look arthroscopy was performed for the following reasons at least one year after ACL reconstruction: (1) skin irritation due to the tibia fixation screw, (2) treatment of meniscus tear, and (3) excision of an intra-articular ganglion cyst.

A modified graft maturation scoring system was used based on previous studies [3, 4, 19, 30, 31]. This evaluation system had four parameters: graft integrity (tear), synovial coverage, graft tension, and graft vascularization. A maximum of two points were assigned to each parameter, depending on the status of the reconstructed graft (Table 1). A ‘complete tear’ was defined as a torn ACL graft without continuity between the proximal and distal stump, ‘partial tear’ as an ACL graft having any torn fibres but with continuity, and ‘no tear’ as no grossly visible torn fibres. Graft tension was evaluated according to side-to-side differences on stress radiographs and the Lachman test: ‘taut’ was defined as a side-to-side difference <3 mm, with a negative Lachman test; ‘lax with firm end point’ was defined as a side-to-side difference >3 mm, with a negative Lachman test; and ‘lax with soft end point’ was defined as a side-to-side difference >3 mm, with a positive Lachman test. Each parameter was scored twice by two blinded observers (orthopaedic surgeons). The inter-observer and intra-observer reliabilities were also evaluated.
Table 1

Graft maturation score system

Score

Graft integrity

Graft synovial coverage (%)

Graft tension

Graft vascularization (%)

2

No tear

>75

Taut

>75

1

Partial tear

25–75

Lax with firm endpoint

25–75

0

Complete tear

<25

Lax with soft endpoint

<25

The total graft maturation score was calculated by adding the scores of the four parameters. Based on the total graft maturation score, graft maturation was rated as excellent (score 7–8), good (score 5–6), fair (score 3–4), and poor (score 0–2) (Figs. 1, 2, 3, 4). The total graft maturation scores and the individual parameter scores were compared between the two groups (HA vs. TA).
Fig. 1

A 48-year-old male patient who underwent anatomic single-bundle anterior cruciate ligament reconstruction with hamstring autograft 35 months ago. The second-look arthroscopic findings show no graft tear (2), >75% synovial coverage (2), and >75% vascularization (2). Side-to-side difference on stress radiography is <3 mm, and Lachman test result is negative. Graft tension is taut (2). According to our rating system, the total graft maturation score is 8 (excellent). Numbers in brackets are the assigned scores

Fig. 2

A 21-year-old male patient who underwent anatomic single-bundle anterior cruciate ligament reconstruction with hamstring autograft 16 months ago. The second-look arthroscopic findings show no graft tear (2), >75% synovial coverage (2), and 25–75% vascularization (1). The side-to-side difference on stress radiography is >3 mm, and the Lachman test result is negative. Graft tension is lax with firm endpoint (1). According to our rating system, the total graft maturation score is 6 (good). Numbers in brackets are the assigned scores

Fig. 3

A 17-year-old male patient who underwent anatomic single-bundle anterior cruciate ligament reconstruction with tibialis anterior allograft 27 months ago. The second-look arthroscopic findings show no graft tear (2), 25–75% synovial coverage (1), and <25% vascularization (0). The side-to-side difference on stress radiography is >3 mm, but the Lachman test result is negative. Graft tension is lax with firm endpoint (1). According to our rating system, the total graft maturation score is 4 (fair). Numbers in brackets are the assigned scores

Fig. 4

A 52-year-old male patient who underwent anatomic single-bundle anterior cruciate ligament reconstruction with tibialis anterior allograft 12 months ago. The second-look arthroscopic findings show total graft tear (0), <25% synovial coverage (0), and <25% vascularization (0). The side-to-side difference on stress radiography is >3 mm, and the Lachman test result is positive. Graft tension is lax with soft endpoint (0). According to our rating system, the total graft maturation score is 0 (poor). Numbers in brackets are the assigned scores

Newly identified meniscus injuries that had not been seen at the time of ACLR were also investigated. Torn grafts were debrided during second-look arthroscopic procedures. Partial meniscectomy or meniscus repair was performed for meniscus tears depending on the status of the meniscus.

This study was approved by the institutional review board of our institution (ID: KUGH16107-003, Korea University Guro Hospital).

Statistical analysis

Sample size was calculated based on the preliminary results of 20 patients (10 in the HA group and 10 in the TA group). The power was set at 0.80, and alpha was set at 0.05. Based on our pilot study, at least 56 patients were required to identify a 1.5-point difference in the graft maturation score (mean of the HA group: 6.0; mean of the TA group: 4.5; standard deviation = 2.0) between the two groups. The preoperative demographic data between the two groups were compared using Pearson’s Chi-square test for sex, independent t test for body mass index (BMI), and Mann–Whitney U test for follow-up period and age. Since the follow-up period was significantly different between the groups and correlated with all of the evaluation parameters as well as the graft maturation score, an analysis of covariance was required to adjust for the ‘follow-up period’ factor. Then, the graft maturation score and each parameter score were compared between the HA and TA groups. All of the results for each parameter were given with one decimal. The intra-observer and inter-observer reliabilities were calculated by using the reliability statistics based on the intra-class correlation coefficient (ICC) for the four evaluation parameters and the graft maturation score. ICC < 0.40 was considered as poor, 0.40–0.59 as fair, 0.60–0.74 as good, and 0.75–1.00 as excellent [11]. Statistical significance was set at p < 0.05 for the comparison of each parameter. Statistical analysis was done using SPSS software for Windows, version 20.0 (SPSS Inc., Chicago, IL, USA).

Results

Fifty-six patients who met the inclusion and exclusion criteria were enrolled. No significant differences in sex, age, and BMI were observed between the two groups (Table 2). Statistical adjustment for the ‘follow-up period’ parameter was performed, and then the mean follow-up period of the two groups was adjusted to 22.5 months. Most patients had an uneventful recovery after ACLR, but had difficulty in returning to the pre-injury level of sports activities. Some patients reported mild discomfort during competitive sports activities.
Table 2

Comparison of demographic data between HA autograft and TA allograft

 

HA (n = 26)

TA (n = 30)

p value

Follow-up period (months)

27.2 ± 8.1

18.4 ± 4.8

0.000

Sex (female:male)

3:23

8:22

n.s.

Age (years)

28.9 ± 10.1

30.8 ± 13.3

n.s.

BMI (kg/m2)

24.8 ± 3.4

24.8 ± 3.5

n.s.

Analysis of covariance was used to adjust for significantly different follow-up periods. The mean follow-up periods of the two groups were adjusted to 22.5 months

HA hamstring, TA tibialis anterior

The results in the HA group were significantly better in terms of graft integrity, graft tension, and graft vascularization. The total graft maturation score of the HA group was significantly higher than that of the TA group (Table 3). The inter- and intra-observer reliability (ICC value) of each parameter was excellent (Table 4).
Table 3

Comparison of graft maturation between the HA autograft and the TA allograft

Parameter

HA (n = 26)

TA (n = 30)

p value

Integrity

1.8 ± 0.1

1.4 ± 0.1

0.041

Synovial coverage

1.3 ± 0.1

1.3 ± 0.1

n.s.

Tension

1.9 ± 0.1

1.5 ± 0.1

0.010

Vascularization

1.3 ± 0.2

0.7 ± 0.2

0.024

Graft maturation score

6.3 ± 0.4

4.9 ± 0.3

0.013

The described scores represent the mean ± standard error, which was estimated to adjust for the ‘follow-up period’ factor by using analysis of covariance. The adjusted mean follow-up period was 22.5 months

HA hamstring, TA tibialis anterior

Table 4

Inter- and intra- observer reliability (ICC value) of each parameter

 

Inter-observer reliability

Intra-observer reliability (1)

Intra-observer reliability (2)

Integrity

0.898

0.949

0.916

Synovial coverage

0.952

0.965

0.920

Tension

0.913

0.964

0.949

Vascularization

0.943

0.923

0.949

Graft maturation score

0.962

0.990

0.963

A higher incidence of partially torn graft was found in the TA group than in the HA group (56.7 vs. 15.4%). Tears were observed at the anteromedial aspect of the tibial insertion in most cases. There was one case of total rupture of the graft at the time of second-look arthroscopy in the TA group (Fig. 4); this patient had no history of traumatic event after primary ACLR. The patient did not want revision surgery because there was no feeling of instability during daily activities.

There were three cases of newly identified meniscus lesions in the HA group; two cases were treated with partial meniscectomy and one case was treated with meniscus repair at the time of second-look arthroscopy. In the TA group, two patients had newly identified meniscus tears, which were treated with partial meniscectomy.

Discussion

In current study, the ACL graft maturation of HA autografts was superior to that of TA allografts, at mean follow-up of 22.5 ± 7.8 months, which was similar to the findings of previous studies that compared the outcomes of second-look arthroscopy between autografts and allografts. Yoo et al. [31] reported that the HA autografts showed considerably better synovial coverage than the TA allografts, based on second-look arthroscopic findings. Lee et al. [21] performed second-look arthroscopy to compare synovial coverage, laxity, and graft abnormalities between autografts and allografts. They concluded that HA autografts showed better synovial coverage on second-look arthroscopy and that better clinical results were found on second-look arthroscopy in the group with better synovial coverage. The results of the current study were similar to those previous studies in that superior results were found with autografts than with allografts, though the rate of partial tear in tibialis allografts was higher than that in hamstring autografts.

It is reasonable to assume that the superior results with HA on second-look arthroscopy are due to the better ligamentization potential of the autograft. Jackson et al. [15] compared patellar tendon autografts and allografts used for ACLR in a goat model. The autograft was associated with decreased inflammatory response, more robust biological response, and improved mechanical and structural properties in comparison with a similar-sized allograft at six months. Dustmann et al. [9] identified that extracellular remodelling in allografts occurs more slowly than in autografts. Hence, they contended that rehabilitation must be adapted to the particular graft and patient.

One interesting finding of second-look arthroscopy is that most of the graft tears occur near the tibial insertion site. Ahn et al. [5] described similar second-look findings of all partial tears occurring at the lateral aspect of the distal third of the grafted tendon, where the graft and notch supposedly are in contact during the range of motion. Our study shows considerably higher tear rates (37.5%) when compared with the findings of Ahn et al. (10%). One possible explanation for this phenomenon is the anterior placement of the intra-articular tibial tunnel in anatomic ACLR where the graft has a higher risk of contact with the notch. Even these partially torn grafts might not affect the knee laxity at the time of second-look arthroscopy. Long-term follow-up is needed in order to rigorously assess graft survival.

Kondo and Yasuda [19] evaluated graft quality on the basis of two parameters: the graft thickness with apparent tension, and the synovial coverage, with each parameter being awarded zero to two points. Several studies have used this method for graft assessment after ACLR [3, 30, 31]. To our knowledge, the current study used the highest number of parameters to evaluate graft quality. Recently, Ahn et al. [4] evaluated the maturation of grafts by using synovial coverage with revascularization, as well as integrity and tension. We also incorporated the parameter of ‘graft vascularization’, since neovascularization is essential to viable grafts and is one of the most important processes for graft remodelling (ligamentization). Thus, the graft maturation scores in the current study represent both the biological aspects and the mechanical properties of the grafts.

Several studies have reported that there is no significant difference in the outcome between an HA autograft and a soft tissue allograft in ACLR [8, 12, 18, 24]. Conversely, Bottoni et al. [7] reported higher long-term failure rates for allografts compared with autografts. The MOON (Multicenter Orthopaedic Outcomes Network) study reported that the allograft re-tear rate is much higher in young and active patients [23]. These studies are supported by the results of current study. The reason for the high survival rate of autografts in young and active patients observed over a long-term follow-up is possibly because only well-maturated, viable grafts can survive the stresses incurred by a high level of activity in the long term.

Nowadays, most orthopaedic surgeons prefer anatomic single-bundle ACLR to non-anatomic ACLR because of improved rotational stability [13, 17, 29]. As the graft is fixed to a non-isometric point in anatomic ACLR, more graft excursion occurs during the range of motion [22], resulting in a high-stress environment for the graft. If the graft cannot resist the stresses during the ligamentization process, the risk of earlier graft failure increases. Therefore, appropriate graft selection is critical in anatomic ACLR as opposed to non-anatomic reconstruction.

This study has several limitations. First, this study has a retrospective, non-randomized design. The follow-up period was significantly different between the groups; thus, statistical adjustment was required. Although sex, age, and BMI were not significantly different between the groups, a selection bias may be present and may have influenced the results of this study. Another selection bias may exist because second-look arthroscopy was not performed in any of the patients who underwent ACLR. Moreover, cases of failed ACL reconstruction requiring revision surgery were excluded from this study. Second, owing to insufficient data on the clinical outcome scores, a statistical correlation between the graft maturation scores and the clinical scores was unable to be obtained. Third, our graft maturation score system needs to be validated.

In spite of these limitations, the evidence of a high long-term failure rate for tibialis allografts is supported by the results of this study. When anatomic ACLR using a soft tissue graft is planned, HA autograft is recommended rather than soft tissue allograft, especially in young and active patients.

Conclusions

This study elucidates the superior graft maturation of HA autografts compared with that of TA allografts at a mean follow-up of 22.5 ± 7.8 months after anatomic single-bundle ACLR.

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest related to this study.

Funding

This study was supported by a grant from Korea University.

Ethical approval

This study was approved by the institutional review board of our institution (ID: KUGH16107-003, Korea University Guro Hospital).

References

  1. 1.
    Abe S, Kurosaka M, Iguchi T, Yoshiya S, Hirohata K (1993) Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction. Arthroscopy 9:394–405CrossRefPubMedGoogle Scholar
  2. 2.
    Ageberg E, Roos HP, Silbernagel KG, Thomee R, Roos EM (2009) Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery. Knee Surg Sports Traumatol Arthrosc 17:162–169CrossRefPubMedGoogle Scholar
  3. 3.
    Ahn JH, Choi SH, Wang JH, Yoo JC, Yim HS, Chang MJ (2011) Outcomes and second-look arthroscopic evaluation after double-bundle anterior cruciate ligament reconstruction with use of a single tibial tunnel. J Bone Joint Surg Am 93:1865–1872CrossRefPubMedGoogle Scholar
  4. 4.
    Ahn JH, Kim JD, Kang HW (2015) Anatomic placement of the femoral tunnels in double-bundle anterior cruciate ligament reconstruction correlates with improved graft maturation and clinical outcomes. Arthroscopy 31:2152–2161CrossRefPubMedGoogle Scholar
  5. 5.
    Ahn JH, Yoo JC, Yang HS, Kim JH, Wang JH (2007) Second-look arthroscopic findings of 208 patients after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 15:242–248CrossRefPubMedGoogle Scholar
  6. 6.
    Amiel D, Kleiner JB, Roux RD, Harwood FL, Akeson WH (1986) The phenomenon of “ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res 4:162–172CrossRefPubMedGoogle Scholar
  7. 7.
    Bottoni CR, Smith EL, Shaha J, Shaha SS, Raybin SG, Tokish JM, Rowles DJ (2015) Autograft versus allograft anterior cruciate ligament reconstruction: a prospective, randomized clinical study with a minimum 10-year follow-up. Am J Sports Med 43:2501–2509CrossRefPubMedGoogle Scholar
  8. 8.
    Cvetanovich GL, Mascarenhas R, Saccomanno MF, Verma NN, Cole BJ, Bush-Joseph CA, Bach BR (2014) Hamstring autograft versus soft-tissue allograft in anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomized controlled trials. Arthroscopy 30:1616–1624CrossRefPubMedGoogle Scholar
  9. 9.
    Dustmann M, Schmidt T, Gangey I, Unterhauser FN, Weiler A, Scheffler SU (2008) The extracellular remodeling of free-soft-tissue autografts and allografts for reconstruction of the anterior cruciate ligament: a comparison study in a sheep model. Knee Surg Sports Traumatol Arthrosc 16:360–369CrossRefPubMedGoogle Scholar
  10. 10.
    Falconiero RP, DiStefano VJ, Cook TM (1998) Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy 14:197–205CrossRefPubMedGoogle Scholar
  11. 11.
    Fleiss JL (1986) Reliability of measurement. The design and analysis of clinical experiments. Wiley, New York, pp 1–32Google Scholar
  12. 12.
    Greis PE, Koch BS, Adams B (2012) Tibialis anterior or posterior allograft anterior cruciate ligament reconstruction versus hamstring autograft reconstruction: an economic analysis in a hospital-based outpatient setting. Arthroscopy 28:1695–1701CrossRefPubMedGoogle Scholar
  13. 13.
    Ho JY, Gardiner A, Shah V, Steiner ME (2009) Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy 25:464–472CrossRefPubMedGoogle Scholar
  14. 14.
    Hu J, Qu J, Xu D, Zhou J, Lu H (2013) Allograft versus autograft for anterior cruciate ligament reconstruction: an up-to-date meta-analysis of prospective studies. Inter Orthop 37:311–320CrossRefGoogle Scholar
  15. 15.
    Jackson DW, Grood ES, Goldstein JD, Rosen MA, Kurzweil PR, Cummings JF, Simon TM (1993) A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med 21:176–185CrossRefPubMedGoogle Scholar
  16. 16.
    Kartus J, Movin T, Karlsson J (2001) Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy 17:971–980CrossRefPubMedGoogle Scholar
  17. 17.
    Kim HS, Seon JK, Jo AR (2013) Current trends in anterior cruciate ligament reconstruction. Knee Surg Relat Res 25(4):165–173CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Kim MH, Yoo MJ, Park HG, Yoo HY, Lee DH (2010) Comparison of the outcomes on second-look arthroscopy after anterior cruciate ligament reconstruction using a hamstring autograft or a tibialis anterior allograft. Knee Surg Relat Res 22(1):25–31Google Scholar
  19. 19.
    Kondo E, Yasuda K (2007) Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy 23:1198–1209CrossRefPubMedGoogle Scholar
  20. 20.
    Lawhorn KW, Howell SM, Traina SM, Gottlieb JE, Meade TD, Freedberg HI (2012) The effect of graft tissue on anterior cruciate ligament outcomes: a multicenter, prospective, randomized controlled trial comparing autograft hamstrings with fresh-frozen anterior tibialis allograft. Arthroscopy 28:1079–1086CrossRefPubMedGoogle Scholar
  21. 21.
    Lee JH, Bae DK, Song SJ, Cho SM, Yoon KH (2010) Comparison of clinical results and second-look arthroscopy findings after arthroscopic anterior cruciate ligament reconstruction using 3 different types of grafts. Arthroscopy 26:41–49CrossRefPubMedGoogle Scholar
  22. 22.
    Lubowitz JH (2014) Anatomic ACL reconstruction produces greater graft length change during knee range-of-motion than transtibial technique. Knee Surg Sports Traumatol Arthrosc 22:1190–1195CrossRefPubMedGoogle Scholar
  23. 23.
    Lynch TS, Parker RD, Patel RM, Andrish JT, Group M, Spindler KP, Amendola A, Brophy RH, Dunn WR, Flanigan DC, Huston LJ, Jones MH, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Pedroza AD, Reinke EK, Wolf BR, Wright RW (2015) The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) research on anterior cruciate ligament reconstruction and orthopaedic practice. J Am Acad Orthop Surg 23:154–163CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Mardani-Kivi M, Karimi-Mobarakeh M, Keyhani S, Saheb-Ekhtiari K, Hashemi-Motlagh K, Sarvi A (2016) Hamstring tendon autograft versus fresh-frozen tibialis posterior allograft in primary arthroscopic anterior cruciate ligament reconstruction: a retrospective cohort study with three to six years follow-up. Int Orthop 40:1905–1911CrossRefPubMedGoogle Scholar
  25. 25.
    Romanini E, D’Angelo F, De Masi S, Adriani E, Magaletti M, Lacorte E, Laricchiuta P, Sagliocca L, Morciano C, Mele A (2010) Graft selection in arthroscopic anterior cruciate ligament reconstruction. J Orthop Traumatol 11:211–219CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Scheffler SU, Schmidt T, Gangey I, Dustmann M, Unterhauser F, Weiler A (2008) Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligament reconstruction: delayed remodeling and inferior mechanical function during long-term healing in sheep. Arthroscopy 24:448–458CrossRefPubMedGoogle Scholar
  27. 27.
    Scheffler SU, Unterhauser FN, Weiler A (2008) Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16:834–842CrossRefPubMedGoogle Scholar
  28. 28.
    Shino K, Kawasaki T, Hirose H, Gotoh I, Inoue M, Ono K (1984) Replacement of the anterior cruciate ligament by an allogeneic tendon graft: an experimental study in the dog. J Bone Joint Surg Br 66:672–681CrossRefPubMedGoogle Scholar
  29. 29.
    Steiner M (2009) Anatomic single-bundle ACL reconstruction. Sports Med Arthrosc 17:247–251CrossRefPubMedGoogle Scholar
  30. 30.
    Yang JH, Yoon JR, Jeong HI, Hwang DH, Woo SJ, Kwon JH, Nha KW (2012) Second-look arthroscopic assessment of arthroscopic single-bundle posterior cruciate ligament reconstruction: comparison of mixed graft versus achilles tendon allograft. Am J Sports Med 40:2052–2060CrossRefPubMedGoogle Scholar
  31. 31.
    Yoo SH, Song EK, Shin YR, Kim SK, Seon JK (2017) Comparison of clinical outcomes and second-look arthroscopic findings after ACL reconstruction using a hamstring autograft or a tibialis allograft. Knee Surg Sports Traumatol Arthrosc 25:1290–1297CrossRefPubMedGoogle Scholar
  32. 32.
    Zaffagnini S, De Pasquale V, Marchesini Reggiani L, Russo A, Agati P, Bacchelli B, Marcacci M (2007) Neoligamentization process of BTPB used for ACL graft: histological evaluation from 6 months to 10 years. Knee 14:87–93CrossRefPubMedGoogle Scholar
  33. 33.
    Zaffagnini S, De Pasquale V, Marchesini Reggiani L, Russo A, Agati P, Bacchelli B, Marcacci M (2010) Electron microscopy of the remodelling process in hamstring tendon used as ACL graft. Knee Surg Sports Traumatol Arthrosc 18:1052–1058CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Korea University Guro HospitalKorea University College of MedicineGuro-gu, SeoulRepublic of Korea
  2. 2.Department of Orthopaedic Surgery, Korea University Ansan HospitalKorea University College of MedicineAnsanRepublic of Korea
  3. 3.Department of Orthopaedic Surgery, Korea University Anam HospitalKorea University College of MedicineSeoulRepublic of Korea
  4. 4.Department of Orthopaedic SurgerySeoul Barunsesang HospitalSeoulRepublic of Korea

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