Hamstring Semitendinosus Auto-Graft Compared to Bone

Report
Hamstring Semitendinosus Auto-Graft Compared to Bone-Patellar TendonBone Auto-Graft in Reconstruction of Anterior Cruciate Ligament for a 20
year-old soccer player
Timothy P. Magee, ATS; Shawn D. Felton, EdD, ATC, LAT; Kaiti Jones, ATC, LAT, CES^
Florida Gulf Coast University, College of Health Professions and Social Work, Fort Myers, FL 33965
Introduction
In this review, the athlete had received his first
ACL surgery using the Hamstring
Semitendinosus auto-graft (HMST). The
rehabilitation process took twelve months and
the athlete was then cleared to play. The athlete
did not feel comfortable enough to play without a
brace for two months following the surgery.
During the two months the athlete did complain
of general knee pain with associated weakness
compared to his other leg. There was no girth
difference measured with girth measurements.
After the two months of participation, while
wearing the brace, the athlete removed the brace
during the third month of play. After one month of
utilizing no brace the athlete reinjured the ACL.
The second surgery used Bone-Patellar TendonBone auto-graft (BPTB) technique. After a nine
month rehabilitation plan, the athlete was in preseason training with the team. The pre-season
training was two weeks long for the first week the
athlete wore the knee brace that was custom
made for his knee. The second week the athlete
was nervous but willing to play without the brace.
As of today there has been no issues with the
athlete. He has been full participation all season.
Hamstring Semitendinosus
Auto-Graft (HMST)
Bone-Patellar Tendon-Bone
Auto-Graft (BPTB)
The auto-graft is harvested from a small
incision over the pes anserine. The
semitendinosus tendon is found and removed
but it is prepared in two different fashions; triple
or quadruple graft style. The femoral tunnel is
drilled transtibially but the tibial tunnels are
drilled in standard fashion. The same location
the Bone Patellar Bone auto-graft (BPTB) was
placed are the same sites for the HMST. Screws
are used to hold the auto-graft in place on both
the femoral and tibial sites. The main advocates
of the HMST auto-graft are the facts that support
smaller cases of anterior knee pain compared to
the BPTB. Osteoarthritis is another major factor
that has been brought into the light about the
advantages for HMST auto-grafts. Since the
BPTB auto-graft has a high result of patients that
present with osteoarthritis the HMST auto-grafts
do not represent with this issue 10 years plus
after surgery.
For the BPTB, an incision is made between
the inferior aspect of the patella to the tibial
tuberosity and the middle third of the patellar
tendon is removed with proximal and distal bone
plugs. Arthroscopy is then performed to position
the graft in the correct area of the meniscus and
femoral condyle and for proper screw fixation.
The bone tunnels are prepared in a standard
transtibial fashion. Once the tunnels are drilled
the bone segments are put into place with
screws. The auto-graft surgery is extremely
useful in the younger and active populations.
The hypothesis for improved results in this
population relates to the faster incorporation
and healing into bone tunnels. The bone will set
into place within 6 weeks, whereas soft-tissue
auto-grafts can take 8-12 weeks or longer to
achieve healing. Knee laxity plays a major roll
into the reconstruction process and the BPTB
auto-graft has demonstrated to have the least
amount of knee laxity compared to all options for
ACL reconstruction.
The purpose of this case review is to inform
athletic trainers of current literature and
rehabilitation practices to treat athletes following
an ACL tear. Since this particular injury is one of
the most common injuries with all athletes today,
research needs to be brought to the attention of
all athletes. This is essential in deciding the best
option on repairing for repair of the ACL. The
research will examine all aspects of the
rehabilitation process, knee laxity, strength, range
of motion, and over all knee pain.
Postoperative Rehabilitation Program
20-year-old Male
Right left dominant
Injury happened to left leg
5th year senior Midfield player
No history of any other injury
First ACL surgery HMST
Second ACL surgery BPTB
PCL sprain
Meniscus Tear
Purpose
Background
Differential Diagnosis
This rehabilitation program below was given to the athlete by the doctor that preformed the surgery. An adjustable
hinged brace was locked in place at 10 degrees of knee flexion for the first week and walked with toe-touch weightbearing using crutches through two weeks. At the end of two weeks the athlete could be at 90 degrees of knee flexion
and all exercises were allowed between 45 and 90 degrees with 5 pounds of weight as tolerated. At week three the
athlete could walk with the brace and without the crutches. Preparatory plyometric exercises could be performed as
tolerated. At five weeks brace was to be discontinued unless the athlete felt unsafe in certain situations. Extend the knee
against resistance and was full range of motion. Swimming and biking without resistance is permitted along with isotonic
motions of the hip, and knee. Eight weeks the athlete was able to extend and flex the knee against unlimited resistance
this was permitted by doctor. The bicycle can be promoted to riding with resistance and submaximal plyometric
exercises. Twelve weeks the athlete was able to do unrestricted isotonic quadriceps strengthening was allowed. At four
months the athlete was running in a straight line and first isokinetic strength testing was performed. At six and eight
months the athlete was performing sports specific exercises and began to return to play.
Hamstring Strain
Strain Gastrocnemius origin
Osteochondral Fracture
Patellar Dislocation
Conclusions
As noted throughout the ten studies reviewed, there was
some conflicting evidence and some evidence that is
valuable. The affected muscle for each auto-graft was
different; the HMST graft affected the hamstrings and the
BPTB graft affected the quadriceps. To benefit most from
these auto-grafts the patients would benefit from going
through a specialized rehabilitation program that would
target the affected muscles. All of the patients in each study
went through the same rehabilitation and as seen in all of the
case studies, different auto-grafts need to go through
different strengthening exercises. The difference of the
affected muscle groups affects the amount of time the patient
is out of play. With the BPTB graft the patients seemed to
return to full activity two to four months sooner than those
that had the HMST graft completed. Unlike the HMST graft,
anterior knee pain is found more often with the BPTB graft.
Knee laxity was discussed a great deal within each study,
determining that with the BPTB graft the athletes have less
laxity in two out of the six studies. Patients within some of
the studies were asked opinionated questions using a sliding
scale. This could affect the overall report because the
conclusion is supported with bias reports. The evidence did
report on many occasions that the data found has one autograft over the other but with no statistical significance.
The many tests done within each study still lead to an
indecisive decision on what auto-graft should be used for
ACL reconstruction. Out of the ten studies reviewed only two
admitted to using the BPTB graft. This reason seemed to be
based off of the rehabilitation program that was
implemented. The focus of many rehab programs for ACL
reconstruction is the quadriceps. As seen in the doctors
rehabilitation plan for this athlete the focus was the
quadriceps. That program was used for both ACL injuries. As
noted in the athletes injury the HMST graft never felt strong
and the athlete had pain in the back of his knee. During the
second auto-graft the athlete followed the same rehabilitation
as he did for the HMST graft. The athlete reported to have a
much better feeling about this graft during the rehabilitation
process. There was no pain within the knee as well. The
athlete is full participation with no complications and is still
playing soccer to this day Overall, the athlete stated that he
would recommend getting the BPTB graft done and it is
imperative to design rehabilitation programs specific to a
given surgery option.

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