Physiotherapy in Toronto for Knee

There are many ways to measure the results of surgery for a torn anterior cruciate ligament (ACL). Pain, stability of the knee, and range-of-motion are commonly used. In this study, quality of life (QOL) is the main measure used to assess outcomes. And for the first time, the two main repair methods are compared using quality of life as the primary measure of results.

Quality of life looks at how the patients view the results. Would they rate their outcomes as poor, fair, good, or excellent? Would they have the same surgery done if they had to do it all over?

The two surgical techniques used to reconstruct a ruptured anterior cruicate ligament are: 1)bone-patellar tendon-bone (BPTB) graft and 2) hamstring graft. In each case, the surgeon harvests a piece of the tendon and uses it to create a replacement for the damaged ligament.

Both of these procedures have advantages and disadvantages. To say one approach is better than the other has been difficult. Many studies have been done to compare them. It's clear that taking a tendon graft from the front of the knee (bone-patellar tendon-bone) makes kneeling painful and sometimes even impossible. Some patients also report numbness or loss of sensitivity at the graft site. Knee pain and difficulty kneeling isn't a problem when using the hamstring graft. Instead, stiffness and decreased stability may develop.

The unique feature of this study is the fact that all patients (a total of 148) were randomly divided into two groups. One group had the bone-patellar tendon-bone graft. The other had the hamstring graft. Everyone was followed and tested periodically for at least eight years. That length of time is considered long-term. All other published studies have been short-term.

Various well-known tests were used to measure health-related quality of life such as the visual analog scale (VAS), the International Knee Documentation Committee (IKDC), Knee Osteoarthritis Outcome Score, and the Short Form-36. Using more than one tool to measure results gives a three-dimensional peek into all areas of the patient's life and how the surgery influenced patient activity and satisfaction.

Here's what they found after gathering all the data and analyzing the difficulty between the two groups. First, there were equal results when comparing knee joint stability and knee function. Stability refers to how stiff versus how loose the joint is when force or load is applied. The stiffer the knee, the more stable it is. Looseness called joint laxity is a sign of an unstable joint. Knee function was defined as a combination of daily activities and sports or recreational activities. Health-related quality of life reflected things like level of pain or other symptoms and how those symptoms affected emotional and mental health.

Second, early reconstructions (within five months of injury) had better results in both groups. This finding was true no matter which type of graft was used. Third, those patients who had a damaged meniscus along with the anterior cruciate ligament injury were more likely to have problems later on. They developed osteoarthritis of the knee and were less likely to continue participating in sports or recreational activities.

And finally, the majority of patients (94 percent) were satisfied and said they had no regrets after their surgery. And in case you are wondering, the bone-patellar tendon-bone group did report knee pain and difficulty kneeling more often than the hamstring group.

The reported results of this study don't end the debate of which technique is best for anterior cruciate ligament reconstruction. But the added information that patient quality of life and satisfaction in the long run are the same between these two repair techniques gives patients and surgeons additional information to consider when choosing one approach over the other.

It would seem from this study that a more important factor in final outcomes is the timing of the surgery. Earlier is better and yields improved results. Patients can be assured that no matter which technique is used, the results will be favorable and satisfaction is likely. For patients who want to avoid the possibility of knee pain with kneeling, the hamstring graft may be the best way to go.

Reference: Björn Barenius, MD, et al. Quality of Life and Clinical Outcome After Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Graft or Quadrupled Semitendinosus Graft. In The American Journal of Sports Medicine. August 2010. Vol. 38. No. 8. Pp. 1533-1541.