Short-Term Recovery After Anterior Cruciate Ligament Reconstruction: A Prospective Comparison of Three Autografts

Abstract

Sixty-four patients with three different autografts were prospectively evaluated following anterior cruciate ligament (ACL) reconstruction for motion return, thigh girth, quadriceps activity, assistive device usage, and duration of pain medication usage. The quadriceps tendon group achieved knee extension sooner than the patellar tendon group. The hamstring group used assistive devices for less time than the patellar tendon group. The quadriceps group required less pain medication than either of the groups. There are significant differences in short-term pain medication requirements and restoration of function among patients following ACL reconstruction using different autografts.

Full text

MARCH 2006 | Volume 29 • Number 3 243
■ Feature Article
abstract
Short-Term Recovery After Anterior
Cruciate Ligament Reconstruction:
A Prospective Comparison of Three
Autografts
MICHAEL JOSEPH, MS, PT; JOHN FULKERSON, MD; CARL NISSEN, MD; T. JOSEPH SHEEHAN, PHD
Mr Joseph is from the University of Connecti-
cut, Storrs, Dr Fulkerson is from the Orthopedics
Associates of Hartford, PC and Drs Fulkerson,
Nissen, and Sheehan are from the University of
Connecticut, Farmington, Conn.
Reprint requests: Michael Joseph, MS, PT,
University of Connecticut, 116 Ledgewood Rd W,
Hartford, CT 06107.
Sixty-four patients with three different autografts were prospectively evalu-
ated following anterior cruciate ligament (ACL) reconstruction for motion
return, thigh girth, quadriceps activity, assistive device usage, and duration
of pain medication usage. The quadriceps tendon group achieved knee ex-
tension sooner than the patellar tendon group. The hamstring group used
assistive devices for less time than the patellar tendon group. The quadri-
ceps group required less pain medication than either of the groups. There
are signifi cant differences in short-term pain medication requirements and
restoration of function among patients following ACL reconstruction using
different autografts.
A
nterior cruciate ligament (ACL)
reconstruction continues to be a
successful operative procedure for
the treatment of symptomatic ACL defi cient
knees. Clancy et al
1
describes intra-articular
ACL reconstruction using the central one-
third of the patellar tendon. Bone-patel-
lar tendon-bone autograft has served as
the “gold standard” of ACL reconstructive
procedures. Complications of bone-patellar
tendon-bone reconstructions include persis-
tent anterior knee pain, patella infera, patella
fracture, and prolonged effusion and postop-
erative pain.
2-7
Donor site morbidity has led
to the increasing popularity of free tendon
ACL grafts, particularly the semitendino-
sus/gracilis tendons
8
and more recently the
central quadriceps free tendon.
9
Proponents of the bone-patellar tendon-
bone graft cite benefi ts of bone-to-bone
fi xation; however, soft-tissue graft fi xation
continues to improve. It is felt by some
authors to be comparable to bone-patellar
tendon-bone fi xation.
10
The greatest ben-
efi t of free tendon grafts may be reduced
short-term postoperative pain and effusion
due to less invasive harvesting procedures.
Decreased pain, swelling, and expeditious
range of motion (ROM) return allows an ac-
celerated course of postoperative rehabilita-
tion while helping to decrease the incidence
of anterior knee pain.
11
Some authors are
concerned with the effects of accelerated
rehabilitation on early fi xation of soft-tis-
sue grafts to bone despite recent advances in
fi xation methods.
12
Choosing the proper ACL graft for the
individual patient is important. Quadrupled
semitendinosus/gracilis is a popular graft
source. Proponents of the double-looped
(quadruple-stranded) semitendinosus/graci-
lis graft claim less donor site complications,
13
less associated quadriceps weakness,
14
and
higher tensile strength as compared to patel-
lar tendon grafts.
15
Concerns of hamstring
grafts include weakness in a prime muscle
agonist to the ACL,
16
reduced initial fi xation
strength,
12
and increased objective laxity
measures in females.
17
Central quadriceps free tendon is a newer
autograft for ACL reconstruction. Blauth,
18
Marshall et al,
19
and Staubli
20
report using
the central quadriceps tendon with a pa-
tella bone block or as part of a composite
graft for ACL reconstruction. More recently
Fulkerson
9
describes the use of the central
quadriceps tendon as a free tendon graft
without patella bone. The central quadriceps
free tendon is harvested from the quadriceps
tendon superior to the patella. This harvest
site supplies a graft that can be 50% larger
than the patellar ligament.
9,21
Benefi ts of the
central quadriceps free tendon are cited as:
preserving the semitendinosus, preventing
anterior knee pain, and reducing the bleed-
ing and patellar fracture risks after bone-pa-
tellar tendon-bone harvest. Early attainment

244 ORTHOPEDICS | www.ORTHOSuperSite.com
■ Feature Article
of ROM, quadriceps return, and elimination
of effusion will prevent many of the com-
plications seen after ACL reconstruction.
Concerns of the central quadriceps free ten-
don graft are similar to the semitendinosus/
gracilis and revolve around early fi xation
strength.
12
This article compares the short-term
experience of the patient after ACL recon-
struction dependent on autograft source.
To our knowledge, no other paper has pro-
spectively compared bone-patellar tendon-
bone, semitendinosus/gracilis, and central
quadriceps free tendon autografts for ACL
reconstruction with respect to the short-
term attainment of rehabilitation bench-
marks and pain medication usage.
MATERIALS AND METHODS
Sixty-four patients were followed pro-
spectively in physical therapy after ACL re-
construction (central quadriceps free tendon
n⫽18; bone-patellar tendon-bone n⫽25;
and semitendinosus/gracilis n⫽ 21). Patients
were enrolled in the study from three sur-
geons (including J.F. and C.N.), each using
one of the three techniques described above.
The choice of graft was based on discus-
sions between the patient and the physician.
Patients were excluded if they had a chronic
ACL insuffi ciency, concomitant meniscal
repair, reported chondral lesion, or signifi -
cant pre-existing anterior knee pain. No dif-
ference existed in age or gender between the
groups. Informed consent was obtained and
the privacy of each patient was protected.
Time to attainment of rehabilitation
benchmarks (full prone knee extension, 120⬚
prone fl exion, equalization of girth mea-
sures, straight leg raise without visible lag,
and time on assistive device) were measured
weekly and daily pain medication usage was
measured from the fi rst postoperative visit
until discharge from therapy. All patients
followed a similar rehabilitation regime (Ta-
ble 1). The number of therapy appointments
ranged between 12 and 32 visits.
Full extension equal to the uninvolved
side was attained when heel heights were
assessed to be equal with the patient prone
and in neutral pelvic alignment as described
by Sachs et al.
7
Goniometric measurements
were taken in prone and noted when 120⬚
of fl exion was attained. Girth measures were
taken at the joint line and 6 cm above the
superior patellar pole and noted when both
measures were within 1 cm of the contralat-
eral side. Joint line measurements indicate
level of effusion. Measurements 6 cm above
the superior patellar pole assess vastus me-
dial obliquus atrophy.
Duration on an assistive device for am-
bulation and amount of pain medication
used was noted. Prescription versus non-
prescription medication was not recorded;
however, the length of time the patient felt
they needed medication for pain relief was
noted.
Data collection was overseen by one
physical therapist (M.J.). All patients, re-
gardless of graft type, followed a uniform
rehabilitation program as the same bench-
Table 1
ACL Rehabilitation Protocol
Weeks
1-2 3-4 5-6 7-8 9-10 11-12
Weight Bearing Full
Brace X
PROM
Extension Full Full Full
Flexion
110
⬚ 125⬚ 135⬚
Patella Mobilization XXX
Strengthening
Quad sets X X X
3-way SLRs X X X
Progression of Closed
Chain Strengthening
XXXXXX
Proprioceptive Training
Balance Activities X X X X X
Multi-Plane Activites X X X X
Conditioning
UBE X X X X X X
Bike (stationary) X X X X X
Stair/Elipse X X
Ski machine X
Postoperative Months 3 4 5 6 7-9
Running Straight
XXXX
Cutting Activities X
Full Sports X
Abbreviations: ACL⫽anterior cruciate ligament, PROM⫽passive range of motion,
SLR⫽straight leg raise, and UBE⫽upper extremity ergometer.

MARCH 2006 | Volume 29 • Number 3 245
ACL RECONSTRUCTION: COMPARISON OF 3 AUTOGRAFTS | JOSPEH ET AL
marks are measured in this study. Our re-
habilitation protocol includes immediate
full ROM, weight bearing and closed chain
activities per patient tolerance, patellar mo-
bilization, and cryotherapy (Table 1).
In addition to summary statistics such
as means and variances, the differences
between benchmark attainment times by
graft types are graphed using box plots.
Bone-patellar tendon-bone was chosen in
advance as the reference method for sin-
gle degree of freedom statistical compari-
sons, as it has been considered the “gold
standard” for ACL reconstruction. Inde-
pendent statistical tests compared semi-
tendinosus/gracilis and central quadriceps
free tendon to bone-patellar tendon-bone,
using analysis of variance (ANOVA) per-
formed using the General Linear Model
in SPSS 10.05 (SPSS Inc, Chicago, Ill).
Assumptions of homogeneity of within
group variances were tested using the
Levene test and if the assumption was vio-
lated, to compare groups, all patients were
split at the median number of weeks to a
particular outcome.
RESULTS
The mean time to attainment of bench-
marks for each of the grafting methods is
displayed in Table 2. The distribution of
weeks to full extension according to graft
type is illustrated in Figure 1. Not only are
there differences between graft types in
number of weeks to recovery, but variation
is far lower for central quadriceps free ten-
don than for bone-patellar tendon-bone or
semitendinosus/gracilis. Such differences in
variation violate the assumption of homo-
geneity of variance underlying the ANOVA
model and are indicated by a signifi cant
Levene test (F⫽4.06, P⫽.022). Although a
signifi cant difference of 3.63 less weeks for
the central quadriceps free tendon method
is detected as compared to the bone-patel-
lar tendon-bone group, the differences in the
variances between 9.49 weeks for the bone-
patellar tendon-bone group as compared to
2.82 weeks for the central quadriceps free
tendon group undermines the validity of that
test.
To compare groups, all patients were
split at the median number of weeks to full
recovery of knee extension. Differences
were tested using a Chi-square with 2⬚ of
freedom. The number of patients above
and below the median number of weeks to
full recovery of knee extension is shown in
Table 3. Only one central quadriceps free
tendon patient falls above the median where
9 patients would be expected under the null
hypothesis of no differences in outcome ac-
cording to graft types (Chi-square
2
⫽20.25,
P⬍.0005). Full extension is reached quicker
and with signifi cantly less variability within
the central quadriceps free tendon group
compared with other groups.
The distribution of weeks until patients
reach 120⬚ prone fl exion is shown in Figure
2. No difference between groups is found
(F
2
⫽1.65, P⫽.2), and neither of the com-
parisons to bone-patellar tendon-bone is
statistically signifi cant. The distribution of
weeks until girth measures are normalized
is shown in Figure 3. Signifi cant differ-
ences are found between groups (F
2
⫽64.15,
P⫽.001), with signifi cant differences of 2.9
weeks favoring semitendinosus/gracilis and
central quadriceps free tendon over bone-
1
Figure 1: Weeks until full prone extension by graft.
Central quadriceps free tendon (CQFT) group
achieved full extension sooner than bone-patel-
lar tendon-bone (BTB) or semitendinosus/gracilis
(ST-G) (P⬍ .0005).
Table 2
Mean Time to Attainment of Benchmarks
Bone-Patellar
Tendon-Bone
Graft (N=25)
Semitendinosus/
Gracilis Graft
(N=21)
Central
Quadriceps Free
Tendon Graft
(N=18)
Full extension (weeks) 7.5 6.4 3.9
120⬚ prone fl exion
5.4 5.4 4.7
Girth measures (cm) 8.4 6.9 5.5
Straight leg raise no lag 4.3 3.7 3.7
Assistive device use 3.1 2.1 2.7
Days on pain medication 22.6 19 5.4
Figure 2: Weeks until 120º of prone-fl exion. No
differences between groups found with ANOVA
(P⬎.200).
2

246 ORTHOPEDICS | www.ORTHOSuperSite.com
■ Feature Article
patellar tendon-bone. However, the Levene
test indicates that the homogeneity of vari-
ance assumption of the ANOVA model
is violated (F
2
⫽5.99, P⫽.004) with vari-
ances of 12.6, 6.35, and 4.32 weeks for the
bone-patellar tendon-bone, semitendinosus/
gracilis, and central quadriceps free tendon
groups respectively. While two out of three
patients in the semitendinosus/gracilis and
central quadriceps free tendon groups equal-
ize girth measures in ⭐6 weeks, two out of
three patients in the bone-patellar tendon-
bone group take ⬎6 weeks to equalize girth
measures (Table 4).
No signifi cant difference in time to
straight leg raise without active extension
lag was found (P⫽.404) (Figure 4).
A statistically signifi cant (P⫽.023) dif-
ference in duration of ambulatory assistive
device use was found (Figure 5). Patients
with a semitendinosus/gracilis graft spent
less time on an assistive device than bone-
patellar tendon-bone grafted patients.
The distribution of patients according to
the number of days it takes to discontinue
use of pain medications is shown in Figure
6. Analysis of variance fi nds signifi cant dif-
ferences between the groups, but the Levene
test rejects the hypothesis of equal within
group variances. The number of patients
above and below the median of 12 days to
discontinue pain medication according to
each graft type is shown in Table 5 (Chi-
Square
2
⫽23.11, P⬍.0005). No patients in
the central quadriceps free tendon group
were above the median of 12 days of pain
medication usage. Patients with a central
quadriceps free tendon graft were on medi-
cation for pain for a signifi cantly shorter du-
ration. These analyses indicate that central
quadriceps free tendon is superior with re-
spect to the number of days before stopping
pain medications.
DISCUSSION
Though each of these graft options has
been acceptable, few comparative studies
exist to guide decisions between them. We
have not found a comprehensive prospective
study evaluating and comparing short-term
patient experience with pain and rehabilita-
tion using these different autografts. This
study was undertaken to evaluate the short-
term experience of patients with three graft
types regarding rehabilitation benchmarks
and analgesic requirements. Hamstring
tendon and quadriceps free tendon ACL re-
constructions were compared to more tradi-
tional patellar tendon reconstructions.
The attainment of full knee extension
has been shown to signifi cantly reduce the
incidence of anterior knee pain.
7,11
Func-
tional knee fl exion, symmetric thigh girth,
Table 3
Number of Patients Above and Below the Overall Median of 5.5
Weeks Until Full Extension Was Achieved
Full Extension
Bone-Patellar
Tendon-Bone
Semitendinosus/
Gracilis
Central
Quadriceps Free
Tendon
⬎Median
18 13 1
⭐Median
7817
Table 4
Number of Patients Above and Below the Overall Median of 6
Weeks For Patients to Normalize Girth Measures
Girth (cm)
Bone-Patellar
Tendon-Bone
Semitendinosus/
Gracilis
Central Quadriceps
Free Tendon
⬎Median
17 7 6
⭐Median
81412
Figure 3: Weeks until girth measures at the joint line
and 6 cm above the patella are within 1 cm by graft
type. The central quadriceps free tendon (CQFT) and
semitendinosus/gracilis (ST-G) groups each achieve
normalized girth measures sooner than the bone-
patellar tendon-bone (BTB) group (P⫽.004).
3
Figure 4: Weeks to SLR no lag. No differences
between groups found with ANOVA (P ⫽ .404).
Abbreviations: BTB⫽bone-patellar tendon-bone,
CQFT⫽central quadriceps free tendon, and ST-
G⫽semitendinosus/gracilis.
4

MARCH 2006 | Volume 29 • Number 3 247
ACL RECONSTRUCTION: COMPARISON OF 3 AUTOGRAFTS | JOSPEH ET AL
the ability to perform a straight leg raise,
time of assistive device use, and the dura-
tion on pain medication each were used as
markers for symptomatic postoperative pain
and daily functional ability. We note sig-
nifi cant differences between patellar tendon,
hamstring, and free quadriceps tendon ACL
reconstructions with respect to attainment of
rehabilitation benchmarks.
A brief glance at our data would suggest
the time frames reported for attainment of
benchmarks in this study are slower than
established accelerated ACL rehabilitation
protocols.
11
We attribute this to several fac-
tors. All measures were taken prior to ex-
ercise and treatment and therefore are not
infl uenced by warm-up or an acute bout of
stretching. We feel measuring full knee hy-
perextension by prone heel heights is a more
sensitive measure than goniometry. Patients
with a central quadriceps free tendon graft
attained symmetric prone heel height earlier
than the other groups. We did not attempt to
quantify the amount of extension lag; there-
fore, even a small defi cit in passive prone
knee extension was captured in our data.
Patients in the central quadriceps free
tendon group regained full extension, nor-
mal girth measures, and used less pain
medication when compared to the patients
in the bone-patellar tendon-bone group. Pa-
tients in the semitendinosus/gracilis group
regained normal girth measures and spent
less time on ambulatory assistive device
than the bone-patellar tendon-bone group.
Both the semitendinosus/gracilis and central
quadriceps free tendon groups had less ef-
fusion postoperatively. The semitendinosus/
gracilis group spent statistically less time on
crutches than those in the bone-patellar ten-
don-bone group.
Most notably, patients with a central
quadriceps free tendon graft used signifi -
cantly less pain medication. This facilitated
an expedient course of early rehabilitation.
Appropriate activity in the early postopera-
tive period after ACL reconstruction has not
been extensively prospectively studied. It is
possible that procedures affording earlier
functional return and less postoperative pain
may allow inappropriate activities that will
compromise early graft healing.
The use of similar ACL rehabilitation
protocols for patellar tendon reconstructions
and free tendon graft reconstructions is con-
troversial. Even more controversial is the
safety of returning patients with free tendon
graft reconstructions to sports as quickly as
those with patellar tendon reconstructions.
These are often referred to as accelerated
protocols and allow safe return to sports at
approximately six months postoperative-
ly.
11,22,23
This article explores the short-term
experience of patients with a patellar tendon,
hamstring tendon, or quadriceps tendon au-
tograft. While defi nite differences are dem-
onstrated in short-term experience between
grafts, long-term follow-up is needed relat-
ing short-term experience with arthrometric
stability and return to athletic/recreational
participation.
The patients with central quadriceps free
tendon autografts have been followed for a
minimum of one year postoperatively and at
this point there have been no differences in
failure rates (by arthrometric analysis) or in
their ability to return to athletic activity.
24
An
evaluation of this group at a two-year mini-
mum follow-up is underway.
CONCLUSION
An infrequently studied parameter of
ACL reconstruction success is the short-
term attainment of rehabilitation bench-
marks, pain reduction, and ability to return
to normal day-to-day functional levels
quickly and safely. We have shown that cen-
tral quadriceps free tendon and hamstring
Table 5
Number of Patients Above and Below the Overall Median of 12
Days to Stop Using Pain Medication
Duration of
Medication Usage
Bone-Patellar
Tendon-Bone
Semitendinosus/
Gracilis
Central Quadriceps
Free Tendon
⬎Median
18 12 0
⭐Median
7918
Figure 5: Weeks until no assistive device was used.
The semitendinosus/gracilis (ST-G) group discon-
tinued use of an assistive device sooner than the
bone-patellar tendon-bone (BTB) group (P⫽.023).
Figure 6: Number of days until medication was
not needed for pain. The central quadriceps free
tendon (CQFT) group discontinued use of medica-
tion for pain relief sooner than bone-patellar ten-
don-bone (BTB) or semitendinosus/gracilis groups
(ST-G) (P⬍.0005).
5
6

248 ORTHOPEDICS | www.ORTHOSuperSite.com
■ Feature Article
semitendinosus/gracilis autografts allow
an earlier return to non-strenuous daily ac-
tivities in a safe manner. Patients experience
less disruption in their daily lives, an easier
postoperative and rehabilitative course, and
therefore less economic burden and reduced
risk of stiffness and prolonged pain. Patients
with a central quadriceps free tendon graft
used signifi cantly less postoperative pain
medication than the other autograft patients.
Short-term experience has proven to be
different among autografts for ACL recon-
struction.
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What is already known on this topic
■ There are several alternative autografts for ACL reconstruction.
■ Multiple studies compare the long-term (⬎2 years) performance of patellar tendon
and hamstring autografts.
■ This article is the fi rst to prospectively compare bone-patellar tendon-bone,
quadrupled semitendinosus/gracilis, and central quadriceps free tendon autografts
for ACL reconstruction with respect to the short-term attainment of rehabilitation
benchmarks and medication usage.
What this article adds