Foor-strand hamstring tendon aotograft versos LARS artificialligament for anterior crociate

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!ntematinal Orthpaedics (SICOT) DOI IO.IOO7/s00264-009-0768-3 Fr-strand hamstring tendn atgraft verss LARS artificialligament fr anterir crciate ligament recnstrctin Zhng-tang Liu.Xian-Ing Zhang.

Bing-Fang Zeng Received: 9 February 2009lRevised: 23 February 20091 Accepted: 23 February 2009 @ Springer-Verlag 2009 Abstract This retrspective study cmpared the results after anterir cruciate

with a minimum fur-year fllw-up. The KT-1000 examinatin, the Intematinal Knee Dcumentatin Cmmittee (IKDC) scring systems and Lyshlm knee scring scale were used t evaluate the clinical results.

1 !ntematinal Orthpaedics (SICOT) DOI IO.IOO7/s Fr-strand hamstring tendn atgraft verss LARS artificialligament fr anterir crciate ligament recnstrctin Zhng-tang Liu.Xian-Ing Zhang.Ya Jiang. Bing-Fang Zeng Received: 9 February 2009lRevised: 23 February Accepted: 23 February Springer-Verlag 2009 Abstract This retrspective study cmpared the results after anterir cruciate ligament (ACL) recnstructin using a fur-strand hamstring tendn graft (4SHG) versus Ligament Advanced Reinfrcement System (LARS) artificial ligament in 60 patients between January 2003 and July 2004 with a minimum fur-year fllw-up. The KT-1000 examinatin, the Intematinal Knee Dcumentatin Cmmittee (IKDC) scring systems and Lyshlm knee scring scale were used t evaluate the clinical results. The mean side-t-side difference was 2.4:1:0.5 mm and 1.2:1:0.3 mm in the 4SHG grup and LARS grup, respectively (P=0.013). Althugh ther results f ACL recnstructin, measured by IKDC evaluatin, Lyshlm scres and Tegner scres, shwed using a LARS graft clinically tended t be superir t using a 4SHG, there were n significant differences calculated. Our results suggest ~ ~PltN Itft~r A~T.!e~n~~ctin using a LARS li~ament r 4SHG dramat-..ic!llyimprves thefun~tin ut~qme. whi1e the patients in the LARS grup displayed a higher knee stability thse in the 4SHG grup. Z.-t. Liu. X.-I. Zhang.Y. Jiang.B.-F. Zeng (~) Department f Orthpaedic Surgery. Arthritis Institute. Shanghai Sixth Peple.s Hspital, Medicai Cl!ege f Shanghai Jia Tng University. 600 Yishan Rad, Shanghai. CT , Peple's Republic f China surgen_zeng@163.cm Z.-t. Liu surgen_iiu@163.cm than Intrductin Arthrscpically assisted anterir cruciate ligament (ACL) recnstructin has been widely used fr patients with anterir knee laxity, and gd clinical results have been btained fllwing the advances in arthrscpic surgery. Hwever, the best chice f tissue graft fr use in ACL, recnstructin has remained the subject f cntrversy. Fr the past tw decades, the bne-patellar tendn-bne (BPTB) autgraft has been cnsidered the gld standard in ACL recnstructin because f its sseus fixatin mde, but increasingly the hamstring tendn (HT) graft has been used as an alternative t the BPTB graft due t the reduced dnr site mrbidity and significantly imprved fixatin techniques [l, 2]. Nevertheless, regardless f the graft type, there can be a degree f mrbidity fllwing autgmft harvest, which may negatively affect recvery after ACL recnstructin [1-3]. Therefre, t avid thse mrbidities assciated with autgraft harvest, use f artificial ligaments may ffer an alternative frm f treatrnent. The use f synthetic material fr ligament recnstructin was recmmended in the 1980s. After a preliminary perid f enthusiasm fr these implants, their ppularity declined because f the high device failure rate and reactive synvitis caused by wear particles. The Ligament Advanced Reinfrcement System (LARS) artificial ligament (Surgical Implants and Devices, Arc-sur- Tille, France) has recently been reprted t be a suitable device due t its special design, and satisfactry clinical results have been btained fllwing its use in ACL recnstructin [4-8]. Hwever, there have been few studies fcusing specifically n cmparing the autgrafts and the LARS artificial Published nline: 25 Apri] 2009

lntematinal Orthpaedics (SICOT) ligaments in ACL recnstructin.

T ur knwledge it is the lngest fllw-up after ACL recnstructin with the LARS ligament in the literature.

The diagnsis f ligament rupture was identified by anterir drawer test, psitive psterir sag sign and magnetic resnance imaging (MRI) [9].

Furthermre, patients with a fllw-up perid f less than fur years were excluded. Sixty patients fulfilled these criteria and were included in this study.

2 lntematinal Orthpaedics (SICOT) ligaments in ACL recnstructin. The aim f this study was t cmpare the utcme after ACL recnstructin using either a fur-strand hamstring tendn graft (4SHG) r a LARS ligament and assess the effectiveness f the tw grafts. T ur knwledge it is the lngest fllw-up after ACL recnstructin with the LARS ligament in the literature. Materials and methds This retrspective study evaluated 60 patients wh underwent ACL recnstructin fr islated ACL rupture between January 2003 and July The diagnsis f ligament rupture was identified by anterir drawer test, psitive psterir sag sign and magnetic resnance imaging (MRI) [9]. The exclusin criteria were a cmbined ligament injury, radigraphically visible degenerative changes, previus knee surgery histry and cntralateral knee ligament injury. Furthermre, patients with a fllw-up perid f less than fur years were excluded. Sixty patients fulfilled these criteria and were included in this study. In the first half fthe study perid, the ACL was recnstructed with a 4SHG in 32 patients, and in the secnd half f the study perid, the ACL was recnstructed with a LARS ligament in 28 patients. The grups were cmparable in terms f gender, age, cause f injury, time frm injury t peratin and preperative Lyshlm and Tegner scres (P > 0.05) (Table J.). Each patient was fully infrmed f the disease details and the surgical prcedures. Surgical technique One senir surgen perfrmed ali f the prcedures. After adequate anaesthesia, standard anterlateral and antermedial prtals were fashined. Preliminary diagnstic arthrscpy was perfrmed and ACL rupture was cnfirmed visua1ly. Meanwhile, the cnditin f a1l f the relevant anatmical structures was evaluated and the extent f the ligament tear and any assciated injuries f meniscus r cartilage was identified. The meniscal lesins fund were treated by partial menisectmy and the cartilage lesins by debridement. In the LARS grup, the partial ACL stump was debrided with a shaver. If there was n effect n the field f view r manipulatin, the ACL stump with synvial cvering was preserved as much as pssible. The bne tunnels were prepared in a standard transtibial fashin. The tibial tunnel was placed just anterir t the nrmal psterir cruciate ligament between the mediai and lateral tibial eminences and the femral tunnel was placed at apprximately 10:30 in the right knee (r 1:30 in the left knee) [10]. The bne tunnels were created with a cannulated drill t a size that matched the diameter f the graft. Frm the tibial prtai, a wire lp was passed thrugh the tibial tunnel int the jint, then thrugh the femral tunnel and the lateral thigh. The sutures at the end f the 4SHGLARS were passed in the lp and the graft was pulled thrugh the jint and sseus tunnels filled with bth end segments f the graft when the wire lp was pulled ut f the femral and tibial tunnels. A cannulated interference screw was driven alng a guide pin inserted thrugh the gap between the graft and the sseus tunnel wall t secure the graft at the femral side. A maximal manual tensin was applied t the distai sutures f the graft and the knee was cycled thrugh full flexin t extensin several times fr graft pretensining and settling. The knee was then placed at 70 flexin and firm tractin was applied t the graft. Then the tendn end f the graft was fixed t the antermedial tibia by using an interference screw in a similar way t the femral side. In the 4SHG grup, the semitendinsus tendn (ST) and gracilis tendn (GT) were harvested and transected at 20 cm. The tendns were prepared t frm a quadruple stranded graft. The fur-strand tendn was then sutured tgether at a pint 3 cm frm the distai end and the prximal end in a running baseball whipstitch mde using n.2 absrbable suture; meanwhile, the suture ends were retained lng enugh as pulling suture. Bth the femral and the tibial tunnels were placed at the same lcatins as in the LARS grup. Meanwhile, the fur-strand tendn graft was passed thrugh the bne tunnels and fixed by the same methd as in the LARS grup. Pstperative rehabilitatin Pstperatively ditterent rehabilitatin the patients in the tw grups used a prtcl due t the time necessary Table 1 Preperative demgraphics in the 4SHG and LARS grups Grup Male/ remale Mean age at surgery (range) (years) Mean time l surgery (range) (mnths) Lyshlm scre (mean :!: SO) Tegner scre (mean :I: SO) 4SHG LARS (20--56) 36 (18-54) II (5-33) 8 (4-34) 43.8% % :!: :!:0.6

Intematinal Orthpaedics (SICOT) fr the 4SHG t fulfil 'ligamentisatin'.

Knee f1exin began frm 45 and increased gradually t the cmplete f1exin and extensin within ne week. Patients usually walked with the help f crutch frm three days fllwing surgery.

The patients were allwed t participate in nn-cmpetitive sprts after the secnd mnth and then were given full freedm in their activities between three and fur mnths fllwing recnstructin.

3 Intematinal Orthpaedics (SICOT) fr the 4SHG t fulfil 'ligamentisatin'. In the LARS grup, quadriceps ismetric exercises, straight leg raises and knee f1exin exercises were initiated frm the first day fllwing surgery. Knee f1exin began frm 45 and increased gradually t the cmplete f1exin and extensin within ne week. Patients usually walked with the help f crutch frm three days fllwing surgery. The crutch was discarded after three weeks. The patients were allwed t participate in nn-cmpetitive sprts after the secnd mnth and then were given full freedm in their activities between three and fur mnths fllwing recnstructin. In the 4SHG grup, a hinged brace lcked between -10 and +90 was used t prevent hyperextensin and prevent inadvertent f1exin while walking fr the first tw mnths. Quadriceps ismetric exercises and straight leg raises were initiated as early as pssible. Fr the first three weeks nly static stepping fr balance was allwed, and then the f1exin exercises were started. Full weight-bearing was allwed after ten weeks withut use f a brace. Flexin beynd 120 was allwed after the third mnth. Patients usually retumed t nrmal daily activity in three mnths and retumed t nn-cmpetitive activity after the sixth mnth. Resumptin f full pre-injury sprts activities culd he undertaken after the ninth mnth. FVRhlRtinn The minimum fllw-up was 48 mnths, and the mean fllw-up was 49 mnths (range: mnths). All examinatins and results were evaluated at fllw-up by a single rthpaedic surgen wh was nt invlved in the patients' care. All patients were evaluated using the KTlOOO arthrmeter test, Intematinal Knee Dcumentatin Cmmittee (IKDC) scring systems, Lyshlm knee scring scale and Tegner activity level. The evaluatin data at the latest fllw-up were gathered and statistically analysed with SPSS 11.0 sftware. The results were cmpared between the tw grups using the unpaired Student's t test fr cntinuus measurements, chi-square test fr the nminai data and Wilcxn signed rank test fr rdered categrical variables, respectively. A p value f <0.05 was cnsidered statistically significant. Results At arthrscpic examinatin, in the 4SHG grup there were eight mediai meniscai tears, fur IateraI meniscai tears and nine catiiage Iesins and in the LARS grup nine mediai meniscai tears, three IateraI meniscai tears and ten cartiiage Iesins. As shwn in TabIe 2, knee stabiiity assessed by KT-1000 arthrmeter (30 flexin and 134 N) shwed that the mean side-t-side difference was 2.4:!: 0.5 mm and 1.2:!:0.3 mm in the 4SHG grup and LARS grup, respectiveiy (P=0.OI3). The side.t-side difference was Iess than 3 mm in 22 patients (73.9%) in the 4SHG grup and 26 patients (95.8%) in the LARS grup, 3-5 mm in 7 patients in the 4SHG grup and tw patients in the LARS grup and mre than 5 mm in three patients in the 4SHG grup but n patient in the LARS grup, respectiveiy (P=0.029). The stabiiity resuits shwed that the LARS grup had significantiy Iess anterir dispiacement than the 4SHG grup. Pstperative assessments f knee functin are summarised in TabIe 3. In terms f IKDC evaiuatin system, 28 patients (87.5%) in the 4SHG grup were graded as nrmai r nearly nrmal and 26 patients (92.9%) in the LARS grup (P=0.523). The mean Lyshlm scres were 92.1:!: 7.9 and 94.6:!:9.2 (P=0.259), and the mean Tegner scres were 6.2:!: 1.6 and 6.6:!: 1.8 (P=0.387) in the 4SHG grup and the LARS grup, respectively. There was n significant difference between the tw grups with respect t the three types f assessment results. The ne-leg hp test was nrmal in 25 cases and 25 cases, nearly nrmal in five cases and three cases and abnrmal in tw cases and n case in the 4SHG grup and the LARS grup, respectively, which did nt reveal significant differences between the tw grups (P=0.382). AlI f the patients in bth grups achieved fuii knee extensin. Apart frm three patients in the 4SHG grup, tw f whm had a Iss f 5 f fuli flexin and ne deveiped arthrfibrsis, ali f the patients in bth grups had nrmal flexin. In bth grups, there were n immediate pstperative cmplicatins that required reperatin r readmissin. One patient in the LARS grup required remval f the tibial screw because it was painful. Table 2 Pstperative examinatin results KT-1OOO Grup Side-t-side difference (N. r patients ) Average (mean:f:sd) <3mm 3-5mm 6-10mm > 1 /)mm 4SHG (n=32) LARS (n=28) O 2.4:!:0.5 mm 1.2:!:0.3 mm p value P=()()2Q P=0.013 ~ Sprinl(er

Internatinal Orthpaedics (SICOT) Table 3 Pstperative knee functin examinatin results Grup Final IKDC rating results Lvshlm scre (mean :I: SO) Tegner scre (mean :I: SD) Nnnal Nearly nnnal Abnrmal

387 Discussin This midtenn fllw-up f ACL recnstructin shwed n significant differences between LARS ligament and 4SHG in tenns f the knee functin examinatin, including IKDC evaluatin, Lyshlm scres and

4 Internatinal Orthpaedics (SICOT) Table 3 Pstperative knee functin examinatin results Grup Final IKDC rating results Lvshlm scre (mean :I: SO) Tegner scre (mean :I: SD) Nnnal Nearly nnnal Abnrmal Severelv abnnl1al 4SHG (n=32) LARS (n=28) p value P=O P=O :1: :1: :!: :!:1.8 P=O.387 Discussin This midtenn fllw-up f ACL recnstructin shwed n significant differences between LARS ligament and 4SHG in tenns f the knee functin examinatin, including IKDC evaluatin, Lyshlm scres and Tegner scres. Hwever, the pstperative a.r laxi was si ificantl lesswith the LA~S lig~entir ~CL ~c~n than with the ~ - Cmpared with BPTB autgraft, the multiple-strand HT graft has becme increasing ppular in recent years because f lwer mrbidity, particularly with respect t anterir knee pain and extensin deficit [1, 2]. Due t the length limitatin f the hamstring tendn, the 4SHG was usually used t recnstruct the injured ACL, f which the initial strength is nearly 2.5 times the nnnal ACL [Il, 12]. There are many reprts specially cmparing the clinical utcme between BPTB graft and 4SHG which fund n significant evidence t indicate that any graft was superir [13-18]. Hwever, several studies evaluated the knee stability with the KT-1000 examinatin and fund that BPTB patients had greater knee stability than 4SHG patients [J.9-22]. Furthennre, in a prspective study Zha et al. [23] cmpared the 4SHG with the 8SHG fr ACL recnstructin. At a minimum f tw years fllw-up, regarding the clinical utcme, either knee stabi.lity r knee functin, ACL recnstructin with 8SHG yields significant.ly better results than recnstructin with 4SHG. Yasuda et a1.. [24, 25] reprted that after ACL recnstructin using 6SHG, ali f their patients btained nnna.l r near-nnnal stabi.lity. These results might mean that thugh the 4SHG has been used as an alternative t the BPTB autgraft in recent years fr ACL recnstructin, it may nt be the best chice due t its insufficient strength. The ultimate tensile strength f the human femur- ACL-tibia cmplex has been estimated as 1,725-2,160 N cmpared t 4,213 N fr the 4SHG [J..l, J.2]. This suggests that the initial strength f the 4SHG shuld be adequate fr the ACL recnstructin. Hwever, autgrafts have t underg 'ligamentisatin " which takes nearly ne year and is prne t cllapse and lsening during this curse [26]. Dustmann et a1.. [27] recnstructed the ACL with a superficial f1exr digital muscle tendn in a sheep mdel. At ne year pstperatively they fund that neither anterpsterir (AP) laxity nr structural prperties f the intact ACL were fully restred. There are n available studies in the current literature that researched the graft strength during and after the curse f 'ligamentisatin' and statistically cmpared it with the nrmal ACL. But the utcme demnstrated abve that better stability can be btained when strands f HT are J increased may mean that the strength f the 4SHG decreased after recnstructin. Cmpared with the 4SHG grup in this study, the results f knee laxity examinatin were better in the LARS grup. Differing greatly ftm the lder types f artificial ligament, the LARS ligament is made ftm an industriai strength plyester fibre and pssesses sufficient strength as a graft fr ACL recnstructin, 2,500 N r 3,600 N crrespnding t 60 gauge r 80 gauge. Meanwhile, its elasticity is very lw. Suffering persistent l, 700 N tractin and being relaxed in 24 hurs, the increased length is less than 1.5%. Furthermre, designed t mimic the nrmal anatmical ligament fibres, the intra-articular lngitudina1 fibres f the LARS ligament resist fatigue and allw fibrblastic ingrwth, and the extra-articular wven fibres prvide strength and resistance t elngatin. There are several studies reprting use f the LARS artificial ligament fr ACL recnstructin [4-7]. The utcme was encuraging and patients shwed a high degree f satisfactin fr the activities f daily living. Furthermre, Nau et al. [6] cmpared the BPTB graft with the LARS ligament in ACL recnstructin and demnstrated that the Knee and Ostearthritis Outcme Scre (KOOS) evaluatin and instrument-tested laxity were better in the LARS grup at the ne-year fllw-up. High device failure rate and reactive synvitis caused by wear particles have been reprted as the main cntra-indicatin t synthetic material fr ligament recnstructin. -~~- In this study we --- did nt find an bvius si with res t li ament rupture wit.hin the fu~~ fllqw-u~ It is pssible that sme f the LARS" ligament fibres have been wm, which cannt be perceived by physical examinatin. fyl;!!!ermre, nne~ the patients reprted here had clinically evident synvitis wrffi~f;:year fll~w"bichcfrespootts LU rllt: reprts f ther authrs [4-8].

lnternatinal Orthpaedics (SICOT) Our study indicates that fur years after ACL recnstructin using a LARS ligament r 4SHG the functinal utcme f the affected kriee has dramatically imprved, while the

Feller J, Webster K, Gavin B (2001) Early pst-perative mrbidity fllwing anterir cruciate ligament recnstructin: patellar tendn versus hamstring graft. Knee Surg Sprts Traumatl Arthrsc 9:260-266 2.

Keays S, Bullck-Saxtn J, Keays A, Newcmbe p (2001) Muscle strength and functin befre and after anterir cruciate ligament recnstructin using semitendinsus and gracilis. Knee 8:229-234 4.

5 lnternatinal Orthpaedics (SICOT) Our study indicates that fur years after ACL recnstructin using a LARS ligament r 4SHG the functinal utcme f the affected kriee has dramatically imprved, while the patients in the LARS grup displayed a higher knee stability than thse in the 4SHG grup. References I. Feller J, Webster K, Gavin B (2001) Early pst-perative mrbidity fllwing anterir cruciate ligament recnstructin: patellar tendn versus hamstring graft. Knee Surg Sprts Traumatl Arthrsc 9: Weiler A, Schemer S, Hher J (2002) Transplant selectin fr primary replacement f the anterir cruciate ligament (in Gerrnan). Orthpade 31(8): Keays S, Bullck-Saxtn J, Keays A, Newcmbe p (2001) Muscle strength and functin befre and after anterir cruciate ligament recnstructin using semitendinsus and gracilis. Knee 8: Dericks G Jr (1995) Ligament advanced reinfrcement system anterir cruciate ligament recnstructin. Op Tech Sprts Med 3: Lavie P, Fletcher J, Duval N (2000) Patient satisfactin needs as related t knee stability and bjective findings after ACL recnstructin using the LARS artificialligament. Knee 7: Nau T, Lavie P, Duval N (2002) A new generatin f artificial ligaments in recnstructin fthe anterir cruciate ligament. Twyear fllw-up f a randmised trial. J Bne Jint Surg Br 84: Trieb K, Blahvec H, Brand G, Sabeti M, Dminkus M, Ktz R (2004) In viv and in vitr cellular ingrwth int a new generatin fartificialligaments. Eur Surg Res 36: Talbt M, Berry G, Fernandes J, Ranger P (2004) Knee dislcatins: experience at the Hòpital du Sacre-Ceur de Mntreal. Can J Surg 47: Rayan F, Bhnsle S, Shukla DD (2009) Clinical, MRI, and arthrscpic crrelatin in meniscal and anterir cruciate 1igament injuries. Int Orthp 33(1): Epub 2008 Feb Gu L, Yang L, Wang AM, Wang XY, Dai G (2009) Rentgengraphic measurement study fr lcating femral insertin site f anterir cruciate ligament: a cadaveric study with X-Caliper. Int Orthp 33(1): Epub 2008 May 7 II. Zarzycki W, Mazurl<iewicz S, Wisniewski P( 1999) Research n strength f the grafts that are used in anterir cruciate ligament recnstructin (in Plish). Chir Narzadw Ruchu Ortp PI 64: Harilainen A, Sandelin J, Janssn KA (2005) Crss-pin femral fixatin versus metal interference screw fixatin in anterir cruciate ligament recnstructin with harnstring tendns: results f a cntrlled prspective randmized study with 2-year fllw- Up. Arthrscpy 21(1): Carter T, Edinger S (1999) Iskinetic evaluatin f anterir cruciate ligament recnstructin: hamstring versus patellar tendn. Arthrscpy 15: Beard DJ, Andersn J.L, Davies S, Price AJ, Ddd CA (2001) Hamstring vs. patella tendn fr anterir crnciate ligament recnstructin: a randmised cntrlled trail. Knee 8: Aune AK, Hlm I, Risberg MA, Jensen HK, Steen H (2001) Furstr'dlld hamstring tendn autgraft cmpared with patellar tendnbne autgraft fr anterir crnciate ligament recnstructin. A randmized study with tw-year fllw-up. Am J Sprts Med 29: Erikssn K, Anderberg P, Hamberg P, LOfgren AC, Bredenberg M, Westrnan I, Wredmark T (2001) A cmparisn f quadrnple semitendinsus and patellar tendn grafts in recnstructin f the anterir crnciate ligament. J Bne Jint Surg Br 83: Pinczewski LA, Deehan DJ, Salmn U, Russell VJ, Clingeleffer A (2002) A five-year cmparisn f patellal' tendn versus furstrand hamstring tendn autgraft fr arthrscpic recnstrnctin f the anterir crnciate ligament. Am J Sprts Med 30: Janssn KA, Link E, Sandelin J, Harilainen A (2003) A prspective randmized study f patellar versus hamstring tendn autgrafts fr anterir crnciate ligament recnstructin. Am J Sprts Med 31: Oter AL, Hutchesn L (1993) A cmparisn f the dubled semitendinsus/gracilis and centrai third f the patellar tendn autgrafts in arthrscpic anterir crnciate ligament recnstrnctin. Arthrscpy 9: Feller JA, Webster KE, Gavin B (2001) Early pst-perative mrbidity fllwing anterir crnciate ligament recnstructin: patellar tendn versus hamstring graft. Knee Surg Sprts Traurnatl Arthrsc 9: Shaieb MD, Kan DM, Chang SK, Marnmt JM, Richardsn AB (2002) A prspective randmized cmparisn f patellar tendn versus semitendinsus and gracilis tendn autgrafts f'r anterir crnciate ligament recnstructin. Am J Sprts Med 30: Ejemed L, Kartus J, Sernert N, Khler K, Karlssn J (2003) Patellar tendn r semitendinsus tendn autgrafts fr anterir crnciate ligament recnstructin? A prspective randmized study with a tw-year fllw-up. Am J Sprts Med 31: Zha J, He Y, Wang J (2007) Duble-bundle anterir crnciate ligament recnstructin: fur versus eight strands f hamstring tendn graft. Arthrscpy 23: Yasuda K, Knd E, Ichiyama H, Kitamura N, Tanabe Y et al (2004) Anatmic recnstructin f the antermedial and psterlateral bundles f the anterir crnciate ligament using hamstring tendn grafts. Arthrscpy 20: Yasuda K, Knd E, Ichiyarna H, Tanabe Y, Thyama H (2006) Clinical evaluatin f anatmic duble-bundle anterir crnciate ligament recnstructin prcedure using hamstring tendn grafts: cmparisns amng 3 different prcedures. Arthrscpy 22: Marnm K, Sait M, Yamagishi T, Fujii K (2005) The "Iigamentizatin" prcess in human anterir crnciate ligament recnstructin with autgenus patellar and hamstring tendns: a bichemical study. Am J Sprts Med 33(8): Epub 2005 Jul6 27. Dustrnann M, Schmidt T, Gangey I, untemauser FN, Weiler A, Scheffier SU (2008) The extracellular remdeling f free-sfttissue autgrafts and allgrafts fr recnstructin f the anterir crnciate ligament: a cmparisn study in a sheep mdel. Knee Sur Sn()lt" Traumat()1 Arthrsc 16: Enub 2008 Jan 9

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