Comparative results of subjective assessment by professional athletes of the functional state of the knee joint after anterior cruciate ligament repair with semitendinosus and gracillis tendons or peroneus longus tendon grafts

Aim: to evaluate the subjective functional state of the knee joint in professional athletes after arthroscopic reconstruction of the anterior cruciate ligament depending on the type of the autograft.

Materials and methods: the study included 37 professional athletes, divided into 2 groups. Athletes of the first group underwent arthroscopic ACL reconstruction using hamstring tendon autograft, i. e. semitendinosus and gracillis tendons (ST/GR group). Athletes of the second group underwent reconstruction using peroneus longus autograft (PL group). For subjective evaluation IKDC, Lysholm and Cincinnati questionnaires were used. The significance of differences was assessed using the Mann — Whitney test. Differences were considered significant at p < 0.05.

Results: according to the Cincinnati questionnaire, the median scores of athletes from the ST/GR group was 96.0 points, from the PL group — 100.0 points (Me [Q1; Q3]: 96.0 [91.0; 100.0] and 100.0 [92.3; 100.0], respectively). According to the criteria of the rating scale, the median Lysholm score in points in the ST/GR group was 95.0, and in the PL group — 97.5 points (Me [Q1; Q3]: 95.0 [90.0;100.0] and 97.5 [92.0;100.0], respectively). According to IKDC measurements, the median score in the ST/GR group was 90.8, and in the PL group — 95.4 (Me [Q1; Q3]: 90.8 [81.0; 94.3] and 95.4 [89.1; 98.5], respectively.

Conclusion: peroneus longus tendon autograft can be used for ACL reconstruction in professional athletes.

1. Kaeding C.C., Léger-St-Jean B., Magnussen R.A. Epidemiology and Diagnosis of Anterior Cruciate Ligament Injuries. Clin. Sports Med. 2017;36(1):1–8. https://doi.org/10.1016/j.csm.2016.08.001

2. Sanders T.L., Maradit Kremers H., Bryan A.J., Larson D.R., Dahm D.L., Levy B.A., Stuart M.J., Krych A.J. Incidence of Anterior Cruciate Ligament Tears and Reconstruction: A 21-Year Population-Based Study. Am. J. Sports Med. 2016;44(6):1502–1507. https://doi.org/10.1177/0363546516629944

3. Gianoti S.M., Marshall S.W., Hume P.A., Bunt L. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J. Sci. Med. Sport. 2009;12(6):622–627. https://doi.org/10.1016/j.jsams.2008.07.005

4. Granan L.P., Forssblad M., Lind M., Engebretsen L. The Scandinavian ACL registries 2004-2007: baseline epidemiology. Acta Orthop. 2009;80(5):563–567. https://doi.org/10.3109/17453670903350107

5. Janssen K.W., Orchard J.W., Driscoll T.R., van Mechelen W. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003-2004 to 2007-2008: time for an anterior cruciate ligament register by Scandinavian model? Scand. J. Med. Sci. Sports. 2012;22(4):495–501. https://doi.org/10.1111/j.1600-0838.2010.01253.x

6. Hamrin Senorski E., Svantesson E., Baldari A., Ayeni O.R., Engebretsen L., Franceschi F., Karlsson J., Samuelsson K. Factors that affect patient reported outcome after anterior cruciate ligament reconstruction-a systematic review of the Scandinavian knee ligament registers. Br. J. Sports Med. 2019;53(7):410–417. https://doi.org/10.1136/bjsports-2017-098191

7. Kvist J., Kartus J., Karlsson J., Forssblad M. Results from the Swedish national anterior cruciate ligament register. Arthroscopy. 2014;30(7):803–810. https://doi.org/10.1016/j.arthro.2014.02.036

8. Joseph A.M., Collins C.L., Henke N.M., Yard E.E., Fields S.K., Comstock R.D. A multisport epidemiologic comparison of anterior cruciate ligament injuries in high school athletics. J. Athl. Train. 2013;48(6):810–817. https://doi.org/10.4085/1062-6050-48.6.03

9. Tarka M.C., Davey A., Lonza G.C., O’Brien C.M., Delaney J.P., Endres N.K. Alpine Ski Racing Injuries. Sports Health. 2019;11(3):265–271. https://doi.org/10.1177/1941738119825842

10. Mehl J., Diermeier T., Herbst E., Imhoff A.B., Stoffels T., Zantop T., Petersen W., Achtnich A. Evidence-based concepts for prevention of knee and ACL injuries. 2017 guidelines of the ligament committee of the German Knee Society (DKG). Arch. Orthop. Trauma Surg. 2018;138(1):51–61. https://doi.org/10.1007/s00402-017-2809-5

11. Leys T., Salmon L., Waller A., Linklater J., Pinczewski L. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. Am. J. Sports Med. 2012;40(3):595–605. https://doi.org/10.1177/0363546511430375

12. Snoeker B., Turkiewicz A., Magnusson K., Frobell R., Yu D., Peat G., Englund M. Risk of knee osteoarthritis after different types of knee injuries in young adults: a population-based cohort study. Br. J. Sports Med. 2020;54(12):725–730. https://doi.org/10.1136/bjsports-2019-100959

13. Lien-Iversen T., Morgan D.B., Jensen C., Risberg M.A., Engebretsen L., Viberg B. Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis. Br. J. Sports Med. 2020;54(10):592–598. https://doi.org/10.1136/bjsports-2019-100765

14. Ardern C.L., Sonesson S., Forssblad M., Kvist J. Comparison of patient-reported outcomes among those who chose ACL reconstruction or non-surgical treatment. Scand. J. Med. Sci. Sports. 2017;27(5):535–544. https://doi.org/10.1111/sms.12707

15. Papastergiou S.G., Konstantinidis G.A., Natsis K., Papathanasiou E., Koukoulias N., Papadopoulos A.G. Adequacy of semitendinosus tendon alone for anterior cruciate ligament reconstruction graft and prediction of hamstring graft size by evaluating simple anthropometric parameters. Anat. Res. Int. 2012;2012:424158. https://doi.org/10.1155/2012/424158

16. Webster K.E., Johnson N.R., Hewett T.E., Krych A.J. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients. Clin. Orthop. Relat. Res. 2017;475(10):2459–2468. https://doi.org/10.1007/s11999-017-5278-9

17. Thompson S.M., Salmon L.J., Waller A., Linklater J., Roe J.P., Pinczewski L.A. Twenty-Year Outcome of a Longitudinal Prospective Evaluation of Isolated Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon or Hamstring Autograft. Am. J. Sports Med. 2016;44(12):3083–3094. https://doi.org/10.1177/0363546516658041

18. Xie X., Liu X., Chen Z., Yu Y., Peng S., Li Q. A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. Knee. 2015;22(2):100–110. https://doi.org/10.1016/j.knee.2014.11.014

19. Widner M., Dunleavy M., Lynch S. Outcomes Following ACL Reconstruction Based on Graft Type: Are all Grafts Equivalent? Curr. Rev. Musculoskelet Med. 2019;12(4):460–465. https://doi.org/10.1007/s12178-019-09588-w

20. Goradia V.K., Grana W.A., Pearson S.E. Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts. Arthroscopy. 2006;22(1):80. https://doi.org/10.1016/j.arthro.2005.10.012

21. Burks R.T., Crim J., Fink B.P., Boylan D.N., Greis P.E. The effects of semitendinosus and gracilis harvest in anterior cruciate ligament reconstruction. Arthroscopy. 2005;21(10):1177–1185. https://doi.org/10.1016/j.arthro.2005.07.005

22. Mardani-Kivi M., Karimi-Mobarakeh M., Mirbolook A., Keyhani S., Saheb-Ekhtiari K., Hashemi-Motlagh K., Porteghali P. Predicting the Hamstring Tendon Diameter Using Anthropometric Parameters. Arch. Bone Jt. Surg. 2016;4(4):314–317

23. Mohtadi N.G., Chan D.S., Dainty K.N., Whelan D.B. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst. Rev. 2011;2011(9):CD005960. https://doi.org/10.1002/14651858.CD005960.pub2

24. Samuelsen B.T., Webster K.E., Johnson N.R., Hewett T.E., Krych A.J. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients. Clin. Orthop. Relat. Res. 2017;475(10):2459–2468. https://doi.org/10.1007/s11999-017-5278-9

25. Mouarbes D., Menetrey J., Marot V., Courtot L., Berard E., Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. Am. J. Sports Med. 2019;47(14):3531–3540. https://doi.org/10.1177/0363546518825340

26. Kerimoğlu S., Aynaci O., Saraçoğlu M., Aydin H., Turhan A.U. Peroneus longus tendonu ile ön çapraz bağ rekonstrüksiyonu [Anterior cruciate ligament reconstruction with the peroneus longus tendon]. Acta Orthop. Traumatol. Turc. 2008;42(1):38–43 (Turkish). https://doi.org/10.3944/aott.2008.038

27. Zhao J., Huangfu X. The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source. Am. J. Sports Med. 2012;40(3):662–671. https://doi.org/10.1177/0363546511428782

28. Lychagin A.V., Aliev R.I., Bogatov V.B., Churbanov S.N., Timashev P.S., Muzychenkov A.V., et al. Application of the long fibular tendon in anterior cruciate ligament plastic surgery: biomechanical properties of the graft, correlation relationships. Russian journal of biomechanics. 2020;24(4):432–438 (In Russ.). https://doi.org/10.15593/RZh-Biomeh/2020.4.08

29. He J., Tang Q., Ernst S., Linde M.A., Smolinski P., Wu S., Fu F. Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg. Sports Traumatol. Arthrosc. 2021;29(9):2869–2879. https://doi.org/10.1007/s00167-020-06279-9

30. Bi M., Zhao C., Zhang Q., Cao L., Chen X., Kong M., Bi Q. All-Inside Anterior Cruciate Ligament Reconstruction Using an Anterior Half of the Peroneus Longus Tendon Autograft. Orthop. J. Sports Med. 2021;9(6):2325967121991226. https://doi.org/10.1177/2325967121991226

31. Bi M., Zhao C., Zhang S., Yao B., Hong Z., Bi Q. All-Inside Single-Bundle Reconstruction of the Anterior Cruciate Ligament with the Anterior Half of the Peroneus Longus Tendon Compared to the Semitendinosus Tendon: A Two-Year Follow-Up Study. J. Knee Surg. 2018;31(10):1022–1030. https://doi.org/10.1055/s-0038-1627466

32. Ertogrul R., Varol A., Oc Y., Kilinc B.E. Is Peroneus Longus Allograft Good Alternative for Anterior Cruciate Ligament Reconstruction: a Comparison Study. Acta Chir. Orthop. Traumatol. Cech. 2021;88(1):58–62. https://doi.org/10.1016/j.jsams.2008.07.005

33. He J., Tang Q., Ernst S., Linde M.A., Smolinski P., Wu S., Fu F. Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg. Sports Traumatol. Arthrosc. 2021;29(9):2869–2879. https://doi.org/10.1007/s00167-020-06279-9

34. Rhatomy S., Hartoko L., Setyawan R., Soekarno N.R., Zainal Asikin A.I., Pridianto D., Mustamsir E. Single bundle ACL reconstruction with peroneus longus tendon graft: 2-years follow-up. J. Clin. Orthop. Trauma. 2020;11(Suppl 3):S332–S336. https://doi.org/10.1016/j.jcot.2019.09.004

35. Kozhevnikov E.V., Bazhenov P.A. Plastic recovery of anterior crucial ligament with free autograft out of tendon of long peroneal muscle. Polytrauma. 2011;(1):76–81. (In Russ.).

36. Ardern C.L., Taylor N.F., Feller J.A., Webster K.E. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br. J. Sports Med. 2014;48(21):1543–1552. https://doi.org/10.1136/bjsports-2013-093398

37. Lai C.C.H., Ardern C.L., Feller J.A., Webster K.E. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br. J. Sports Med. 2018;52(2):128–138. https://doi.org/10.1136/bjsports-2016-096836

38. Yabroudi M.A., Irrgang J.J. Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction. Clin. Sports Med. 2013;32(1):165–175. https://doi.org/10.1016/j.csm.2012.08.016

39. van Melick N., van Cingel R.E., Brooijmans F., Neeter C., van Tienen T., Hullegie W., Nijhuis-van der Sanden M.W. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br. J. Sports Med. 2016;50(24):1506–1515. https://doi.org/10.1136/bjsports-2015-095898

40. Marx R.G., Jones E.C., Allen A.A., Altchek D.W., O’Brien S.J., Rodeo S.A., Williams R.J., Warren R.F., Wickiewicz T.L. Reliability, validity, and responsiveness of four knee outcome scales for athletic patients. J. Bone Joint Surg. Am. 2001;83(10):1459–1469. https://doi.org/10.2106/00004623-200110000-00001

41. Shelbourne K.D., Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am. J. Sports Med. 1990;18(3):292–299. https://doi.org/10.1177/036354659001800313

42. Johnson D.S., Smith R.B. Outcome measurement in the ACL deficient knee--what’s the score? Knee. 2001;8(1):51–57. https://doi.org/10.1016/s0968-0160(01)00068-0

43. Tegner Y., Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin. Orthop. Relat. Res. 1985;(198):43–49. https://doi.org/10.1097/00003086-198509000-00007

44. Briggs K.K., Steadman J.R., Hay C.J., Hines S.L. Lysholm score and Tegner activity level in individuals with normal knees. Am. J. Sports Med. 2009;37(5):898–901. https://doi.org/10.1177/0363546508330149

45. Ardern C.L., Webster K.E., Taylor N.F., Feller J.A. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am. J. Sports Med. 2011;39(3):538–543. https://doi.org/10.1177/0363546510384798

46. Runer A., Wierer G., Herbst E., Hepperger C., Herbort M., Gföller P., Hoser C., Fink C. There is no difference between quadricepsand hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patientreported outcome study. Knee Surg. Sports. Traumatol Arthrosc. 2018;26(2):605–614. https://doi.org/10.1007/s00167-017-4554-2