Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials

Arthroscopy. 2009 Oct;25(10):1139-74. doi: 10.1016/j.arthro.2009.07.021.


Purpose: The primary aim was to summarize and assess current evidence from randomized controlled trials (RCTs) on anterior cruciate ligament injuries, with special reference to graft type and surgical technique. The secondary aims were to identify the relative strengths and weaknesses of the selected studies, to resolve contradictions in the literature, and to evaluate the need for further studies.

Methods: A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to RCTs published in English between January 1995 and March 2009. Articles on the subject of graft type and surgical technique were identified. After initial screening and a subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 39 articles were included in this review.

Results: There are no differences between the bone-patellar tendon-bone (BPTB) graft and the hamstring tendon (HT) graft in terms of laxity, clinical outcome, time to return to sports, patellofemoral crepitations, 1-leg hop test, range of motion, thigh muscle circumference, or anterior knee sensory deficit. The BPTB graft produces more anterior knee pain and kneeling pain than the HT graft, but the difference disappears with time. The harvest site affects muscle strength initially but not over time. There is a possible correlation between the development of osteoarthritis and the BPTB graft. The HT graft produces more tunnel widening than the BPTB graft, but there is no correlation between tunnel widening and clinical outcome or laxity. The semitendinosus and gracilis graft is associated with inferior knee flexion at higher angles, as compared with the semitendinosus graft. There are probably no differences between the BPTB graft and the bone-HT-bone graft in terms of laxity and clinical outcome. Semitendinosus and gracilis tendon harvesting probably reduces hamstring muscle strength for approximately 1 year. Double-bundle reconstruction produces less rotatory laxity than single-bundle reconstruction. Double-bundle reconstruction by use of an 8-strand HT graft probably produces less laxity than single-bundle reconstruction. There are no differences in clinical outcome when single-bundle and double-bundle anterior cruciate ligament reconstructions are compared.

Conclusions: In the quality assessment several weaknesses in the study design of the RCTs were found. This emphasizes the need for further high-quality studies, especially with long-term follow-up.

Level of evidence: Level II, systematic review of randomized controlled trials.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Anterior Cruciate Ligament / pathology
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries
  • Arthroscopy / methods*
  • Evidence-Based Medicine
  • Femur / pathology
  • Femur / surgery
  • Humans
  • Joint Instability / prevention & control
  • Knee Joint
  • Patellar Ligament / transplantation
  • Postoperative Complications / prevention & control
  • Randomized Controlled Trials as Topic / statistics & numerical data*
  • Reconstructive Surgical Procedures / methods*
  • Recovery of Function
  • Severity of Illness Index
  • Tendons / transplantation
  • Tibia / pathology
  • Tibia / surgery
  • Transplantation, Autologous
  • Treatment Outcome