ORIGINAL ARTICLE

Anterior cruciate ligament (ACL) autograft reconstructionwith hamstring tendons: clinical research among threerehabilitation procedures

Weimin Zhu • Daping Wang • Yun Han •

Na Zhang • Yanjun Zeng

Received: 31 July 2012 / Accepted: 3 October 2012

� Springer-Verlag France 2012

Abstract

Objective To compare the effects of the three rehabili-

tation procedures following anterior cruciate ligament

(ACL) autograft reconstruction with hamstring tendons.

Design An observational and retrospective case-con-

trolled series.

Setting The Department of Sports Medicine, Shenzhen

Second People Hospital, Shenzhen, PR China.

Patients or participants Forty-five patients who were

made to undergo ACL reconstructions by using quadrupled

semitendinosus and gracilis tendons were divided into

three groups: accelerated rehabilitation procedures group,

aggressive rehabilitation procedures group, and self-made

rehabilitation procedures group.

Main outcome measures The knee range of motion, thigh

perimeter, IKDC score, and bone tunnel diameter in 3D-CT

films were evaluated 3 and 6 months and 1 year later.

Results The knee range of motion and thigh perimeter of

group A were higher than those of group B and group C at

3, 6, and 12 months. IKDC scores of group C were better

than those of groups A and B. The bone tunnel widening

with group B was larger than that with groups A and C, and

the differences were statistically significant (P \ 0.05).

Conclusion Early rehabilitation is beneficial for restora-

tion of knee function after ACL reconstruction. Moderate

procedure is better than accelerated procedure.

Keywords Knee joint � Anterior cruciate ligament �Reconstruction � Rehabilitation � Hamstring tendons

Introduction

The rupture of anterior cruciate ligament (ACL) is the most

common damage of athletes, and the ACL reconstruction

under arthroscopies becomes a common therapy [1]. The long-

term curative effect of ACL reconstruction depends on the

method of reconstruction and rehabilitation after surgery.

Since bone–patellar tendon–bone (B-PT-B) is thought to be the

most effective grafts replacement, the most common clinical

recovery plan is based on B-PT-B feature and the modeling and

healing processes after surgery [2]. But it is replaced by

popliteal muscle (semitendinosus and hamstring muscle)

gradually in the recent years because of many postsurgery

syndromes. There are a lot of differences when comparing

four semitendinosus ligament and stainless steel plate suture

reconstruction ACL with B-PT-B reconstruction. Thus, we

have to make training plan accordingly [3]. In order to provide

the basis for clinical recovery plan, this research expresses the

effects of the different rehabilitation procedures following

ACL autograft reconstruction with hamstring tendons.

Materials and methods

Clinical materials

We recruited 45 patients for this case. Twenty-five of them

were males and others were females aged from 19 to

W. Zhu � D. Wang (&) � Y. Han � N. Zhang

Department of Sports Medical, Shenzhen Second People

Hospital, Sungang West Road, Futian District,

Shenzhen 518000, People’s Republic of China

e-mail: szhzwm@126.com

Y. Zeng (&)

Biomechanics and Medical Information Institute,

Beijing University of Technology, Beijing 100022,

People’s Republic of China

e-mail: yjzeng@bjut.edu.cn; nyjzeng@bjut.edu.cn

123

Eur J Orthop Surg Traumatol

DOI 10.1007/s00590-012-1106-9

39 years. They were randomly divided into 3 groups, 15

patients in each group. Accelerated rehabilitation proce-

dures were taken for group A. Aggressive rehabilitation

procedures were taken for group B. Recovery plan made by

our department was taken for group C.

All of them did not have other ligament injuries and did

not need to meniscus suture or cartilage fixing. They

underwent X-ray examination postoperatively. Preopera-

tive tests include Lachman test, pivot shift tests and Lys-

holm assessment. There were no obvious differences

among comparison groups (P [ 0.05). The same group of

doctors performed the four semitendinosus ligament

reconstruction ACL, endobutton overhang fixing, and tibia

HA biology assuming screw ? door style nail. We fol-

lowed up all the patients for more than half a year after

surgery.

Methods

Group A

Patients lay in bed for 4 weeks, 30 % weight carrying with

crutches for 8 weeks, and 100 % weight carrying for

12 weeks. Brace was fixed within 4 weeks; the degree of

activity was limited to 0�–60�. After 8 weeks, the knees

bend achieves 90�. The temperature became normal after

12 weeks. Closed chain exercises (such as half crouch and

leg pressing) began 8 weeks after the surgery. Open chain

exercises began 12 weeks after surgery. They began run-

ning and swimming practices half a year after the surgery.

Sports activities began to be normal 1 year after the

surgery.

Group B

Patients could bear full weight 2 weeks after surgery and

walk carrying weight with crutches 4 weeks after surgery.

They could walk with the support of brace, which was

removed after 8 weeks. Knee bend of 90� was achieved

after 1 week and 10� increased every following week and

became nearly normal 4 weeks later. Closed chain training

began 2 weeks after surgery, open chain training began

4 weeks after surgery, and running and swimming began

8 weeks after surgery. Sports activities became normal

3 months after the surgery.

Group C

Patients were 30 % weight carrying 2 weeks after the

surgery and full weight carrying 4 weeks after the surgery.

They could walk normally without crutches after 8 weeks

and brace was removed 12 weeks after the surgery. Knee

bend of 90� was achieved 2 weeks after the surgery and

10� increased every following week and became nearly

normal 8 weeks later. Closed chain practice began 4 weeks

after surgery and open chain practice began 8 weeks after

surgery with increased flexibility practice. Sports activities

became normal 6 months after the surgery.

Clinical assessment

We reviewed the 3 groups at 3, 6, and 12 months respec-

tively and compared the quota below.

The joint expansions and bend degree

The knees flexion and extend angle of both knee were

measured by using protractor. The interpolation of the

unhealthy and healthy knee expansions and bend degree is

the measure quota.

Thigh muscle atrophy situation

Thigh cross-section diameter was used as the examination

target. Thigh cross-section diameter was measured with

tape on the 10-cm edge of patella and the interpolation of

both joints was used.

The International Knee Documentation Committee grades

The International Knee Documentation Committee sub-

jective form was used. The total score is 100.

Transplant marrow expansion situation

The patients were undergone CT (3D-CT) examination at

the day of the surgery or 12 months after the surgery and

survey shinbone and thighbone tunnel center point stratifi-

cation plane tunnel width. The interpolation of bone tunnel

was examined the day after the surgery and 12 months after

the surgery.

Statistical method

All data of testing parameters were collected and statisti-

cally processed with SPSS 11.0: t test was used to compare

the data.

Ethical review

The study gained the consent and approval by the Ethics

Review Committee of Shenzhen Second People Hospital,

Shenzhen, PR China. The research group strictly carried

out the requirements of national Ministry of Science and

Technology and Ministry of Public Health document,

which was about strategies to identify and mitigate risks of

Eur J Orthop Surg Traumatol

123

human clinical trials with investigational trial, which is the

process of clinical trials to minimize the risks of the exe-

cution process in accordance with humanitarian principles

of the implementation of the study, with human and animal

ethical requirements, and corresponding obligations and

responsibilities were undertaken by the research group.

Results

Table 1 shows that there are no obvious differences between

the thigh cross-section diameter and IKDC assessment

scores (P [ 0.05). The joint activity aspect: The limitation

angle of expansions and contractions of group A is larger

than groups B and C 3, 6, and 12 months after surgery, and

there is obvious difference (P \ 0.05). There is no obvious

difference between groups B and C (P [ 0.05). Thigh

muscle atrophy situation: Group A is larger than group B 3,

6, and 12 months after surgery, and the difference is obvious

(P \ 0.05). The difference between groups B and C is little

(P[ 0.05). IKDC assessment aspect: Group C is better than

groups A and B 3, 6, and 12 months after the surgery, and

the difference is obvious (P \ 0.05). The difference between

groups B and C is little (P [ 0.05). Bone tunnel aspect:

Group B is larger than groups A and C, and the difference is

obvious (P \ 0.05). There is no obvious difference between

groups A and C (P [ 0.05).

Discussion

The importance of early recovery in ACL

reconstruction

The system recovery exercises can improve the nutrition in

joint cartilage, effectively reduce pain, reduce joint cap-

sules shrink and the scar formation, reduce the rate of

patellofemoral joint pain, and strengthen the function [4].

The lack of rehabilitation in early stage will result in lig-

ament adhesion joint and function barrier. Thus, the early

recovery treatment is very important. The research indi-

cates that the ligament reconstruction by the passive

movement practice, which restores patient’s functions,

involves the following steps [5]: (1) Temperate and lasting

around joint capsule, ligament tendon, and joint soft tissue

can prevent these tissues from shrinking and softening

adhesion, so that it can prevent and correct the joint activity

to a certain limit. (2) Continually passive activities and the

relative activity can increase the joint liquid–fluid pasting

and renewal, so that the nutrition will improve. (3) After

the joint ligament repair, the reconstruction applies the

passive movement to reduce the ligament by atrophy and

remarkably increase the ligament intensity. (4) Continuous

passive movement of the joint make the system feel that it

has the centripetal impulse to provide and may block the

ache signal without ceasing the transmission, thus reducing

Table 1 Assessment result before and after the surgery of each group

Examination quota Time Group A Group B Group C

The joint expansions and bend degree (�)

Angel of unbend 3 months postop. 5.27 ± 1.19# 2.19 ± 1.75 1.50 ± 0.46&

6 months postop. 3.78 ± 1.08# 1.39 ± 0.82 1.25 ± 0.53&

12 months postop. 2.25 ± 0.56# 1.37 ± 0.19 1.27 ± 0.34&

Angel of bend 3 months postop. 20.32 ± 10.21# 11.26 ± 5.72 12.15 ± 3.21&

6 months postop. 1.10 ± 2.18# 4.61 ± 2.92 4.17 ± 3.28&

12 months postop. 5.69 ± 0.92 1.32 ± 0.56 0.89 ± 0.75

Preop. 2.41 ± 1.68 2.35 ± 1.44 2.08 ± 1.02&

Thigh muscle atrophy situation 3 months postop. 4.58 ± 1.26*# 2.29 ± 1.17* 3.72 ± 0.83*&

6 months postop. 3.83 ± 1.05*# 1.97 ± 0.46* 1.86 ± 0.69*&

12 months postop. 2.35 ± 0.62# 1.26 ± 0.57* 1.30 ± 0.70*&

Preop. 60.17 ± 7.34 62.25 ± 5.29 59.19 ± 8.02

IKDC assessment 3 months postop. 65.56 ± 10.11* 72.48 ± 8.23* 78.27 ± 11.49*#

6 months postop. 73.19 ± 16.21* 79.30 ± 11.01* 85.34 ± 5.89*#

12 months postop. 82.26 ± 3.19* 85.21 ± 1.78* 94.72 ± 2.40*#

Bone tunnel expand value Shinbone tunnel 1.37 ± 0.79 3.41 ± 0.52 1.52 ± 029

Thighbone tunnel 1.57 ± 0.48 2.96 ± 1.01# 1.60 ± 0.37

* Comparison with presurgery P \ 0.05# Comparison with the other 2 groups P \ 0.05& Comparison with group B P [ 0.05

Eur J Orthop Surg Traumatol

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the ache. But till now, it is not concluded what kind of

intensity and the frequency recovery procedure are suitable

for reconstruction [6]. To start each kind of function,

training requirements have to be disputed appropriately.

Recovery and transplant biology reconstruction speed

match principle

After the transplant, implants in vivo have to pass through

a series of biological reconstruction processes, including

the transplant necrosis host organization substitutes, the

new biology to model the shape reconstruction and so on

[7]. Among them, the reconstruction of the transplant’s

blood vessel is extremely important, which needs

1–2 years. So far, in ACL surgery, regardless of how the

surgery does heal with the fixed way tendon–bone, the

biology process is consistent, which is the foundation of

the recovery process formulation. Not only before but also

after the technique, the early suitable stress stimulation will

be helpful in restoring the knee joint in environment and

the joint normal main body to feel the circuit to be

advantageous to the knee joint function, which helps in

speedy recovery [8]. But the surmounting biology of

healing process recovery may hinder the healing process

and may even cause failure of the surgery. This research

has formulated the three recovery plans in the normal range

which this biology healed, through to the recovery effect

analysis, and made every effort in the recovery effect and

the speed obtains the relative unification.

The analysis of the result of this experiment

Expansions and contractions of the activity measurement

The joint activity is an important parameter which the joint

function restores. In this experiment, the conservative recov-

ery plan degree is larger than aggressive and self-recovery

plan groups. The result shows that it is better to begin

recovery early, or it will result in joint activity limitation.

Thigh muscle atrophy situation

The four brachium muscles are the main thigh muscle

group which has the vital significance regarding the knee

joint activity and the stability. Shaw studied the impact of

the early training of four brachium muscles toward ACL

postsurgery reconstruction [9]. They discovered that early

exercise of the muscles can improve knee joint activity and

reduce knee joints laxity. Checking the thigh cross-section

diameter, we can know the atrophy situation which reflects

the recovery status directly. The results show that early

(especially in 2 weeks after the surgery) recovery has

advantage to prevent atrophy [10].

IKDC assessment

IKDC assessment is carried out to evaluate the effect of knee

recovery from symptom, function, sports activity, and so on

[11]. In this experiment, we conducted IKDC assessments 3,

6, and 12 months after ACL reconstruction and found that the

score after surgery was higher than that before surgery, which

means the patients have improved feeling, while the self-

recovery group was better than the consecutive group and

aggressive group, which means that the self-recovery group

has better subjective healthy result.

Bone tunnel enlarge situation

Because of the ‘‘pole effect’’ and ‘‘rain wash effect,’’ most

of the patients’ bone tunnel will enlarge, which is one

important element that affects the ACL recovery result in

the long term. Through the 3D-CT examination, we find

that there are bone tunnel enlargement in the 3 groups to

various extend. However, the extent of aggressive recovery

group is obviously larger than the consecutive and self-

recovery groups, which means it is not the more aggressive

the better.

Conclusion

Early recovery should be conducted after ACL surgery.

Consecutive recovery will result in knee joint activity

limitation and muscle atrophy, but if we ignore the objec-

tive law and pursue the progress of recovery, it will result in

bone tunnel enlargement. Thus, moderate ACL reconstruc-

tion might be appropriate for postsurgery recovery of knee

function.

Acknowledgments This study is given the pecuniary supported by

Emerging scientist project of Shenzhen Second People’s Hospital and

the Guangdong Province Medical Research Foundation (the project

number is B2012320).

Conflict of interest There is no conflict of interest among the

authors of this study and no objection to the selection and order of the

authors.

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