title: Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis.
abstract: BACKGROUND
  Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone-patellar tendon-bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts.
  
  
  METHODS
  We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bone-patellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis.
  
  
  RESULTS
  Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32-0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82-1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group.
  
  
  CONCLUSIONS
  Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability.
authors.affiliation: Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, NL-1090 HM Amsterdam, The Netherlands. poolman@trauma.nl
authors.forename: Rudolf W
authors.initials: RW
authors.lastname: Poolman
authors.forename: Forough
authors.initials: F
authors.lastname: Farrokhyar
authors.forename: Mohit
authors.initials: M
authors.lastname: Bhandari
mesh_terms: D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D050376:Bone-Patellar Tendon-Bone Grafting / Q000009:adverse effects / Q000379:methods*; D019317:Evidence-Based Medicine; D006801:Humans; D007718:Knee Injuries / Q000601:surgery; D015201:Meta-Analysis as Topic; D017847:Patellar Ligament / Q000637:transplantation*; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012680:Sensitivity and Specificity; D013710:Tendons / Q000637:transplantation*; D014182:Transplantation, Autologous