ACL Reconstruction with Contralateral Patellar Tendon Grafts
Abstract & Commentary
Synopsis: Patients reconstructed using contralateral patellar tendon grafts achieved range of motion, quadriceps muscle strength, and return to sport faster than patients reconstructed with ipsilateral patellar tendon grafts.
Source: Shelbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med 2000;28(5):651-658.
Acl reconstruction is a commonly performed procedure for the orthopaedic surgeon that generally yields good results that allow an athlete to return to activities. Although the most common graft choice remains the ipsilateral patellar tendon, patient complaints related to graft harvest are common and sometimes activity limiting. Shelbourne and Urch have addressed this problem by using the contralateral patellar tendon as a graft source.
Over a three-year period, Shelbourne and Urch reconstructed 434 patients with contralateral patellar grafts and 228 patients with ipsilateral patellar grafts. Patients with revision reconstructions, prior contralateral ACL injuries, or bilateral injuries were excluded from the original number of 831. The patient made the choice of graft after preoperative counseling. Demographics, percentage of patients involved in competitive sports, and associated meniscal and chondral pathology were similar between groups. All patients followed an aggressive rehabilitation protocol without the use of any brace and with immediate weight bearing. All patients stayed one night in the hospital.
Range of motion was about 10° greater in the contralateral group at each time point up until two months postoperatively. Shelbourne and Urch found that quadriceps strength as assessed by isokinetic testing was greatest in the contralateral ACL reconstructed group at one, two, and four months postoperatively. Athletes with contralateral grafts returned to full sports participation at a mean of 4.9 months postoperatively, compared to 6.1 months for athletes with ipsilateral grafts. The subgroup of competitive athletes returned to full sports at a mean of 4.1 months compared to 5.5 months for the ipsilateral group. Stability, as determined by KT-1000 arthrometry, was equivalent between groups. Modified Noyes subjective scores were equivalent among groups at two-year follow-up, while pain scores were slightly worse in the ipsilateral group. Shelbourne and Urch conclude that use of the contralateral patellar graft results in a faster return of quadriceps strength, quicker return of motion, and earlier return to sports.
Comment by David R. Diduch, MS, MD
Because of donor site morbidity and complications, alternative graft choices to ipsilateral patellar tendon grafts have been explored. Shelbourne and Urch represent a minority who have chosen to harvest the contralateral patellar tendon. By so doing, they maintain the advantages of bone plug fixation and rapid healing within the tunnels as an advantage over soft tissue grafts. Decreased surgical trauma to the reconstructed knee extensor mechanism preserves muscle strength, motion, and accelerates rehabilitation, as one would expect. This paper effectively and objectively measures these variables. Unfortunately, Shelbourne and Urch do not give us a good measure of the difficulty in recovering from bilateral knee surgery. The addition of outcome measures and short-term assessment of pain with visual analogue scales would have been helpful. Nevertheless, it would appear that the contralateral group did very well, given how quickly they regained motion, strength, and activity. It is amazing that in a group of patients this large that Shelbourne and Urch had no patellar fractures, patellar tendon ruptures, or infections.
What is less clear is what advantage, if any, the contralateral patellar tendon has over the use of hamstring grafts. It has been established that hamstring grafts involve less donor site morbidity and preserve greater quadriceps muscle strength. Return to sports would generally be longer as most surgeons restrict patients greater than four months due to the prolonged healing of soft tissue within the tunnels compared to bone plugs. A prospective study with similar comparisons as found in this paper would be useful. Otherwise, it seems that one could argue that use of a hamstring graft has similar advantages while avoiding trauma to the other knee. In my limited experience involving revisions, it is a tough sell to the patient to operate on the opposite knee. Lastly, I wonder if this could be done as an outpatient? Many of us do ACL reconstructions routinely as an outpatient procedure, and managed care dictates this in many locations.
This paper effectively validates the option of using the opposite knee for graft harvest and gives the surgeon helpful information on which to base a decision and counsel the patient. We can conclude that the contralateral patellar graft is a safe, effective graft choice alternative. Obviously, there is more than one way to do things in orthopaedic surgery.
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