Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

DOI 10.1007/s00167-009-0961-3

KNEE

A 2-year follow-up of rehabilitation after ACL reconstruction

using patellar tendon or hamstring tendon grafts:
a prospective randomised outcome study
Annette Heijne Suzanne Werner

Received: 11 July 2009 / Accepted: 5 October 2009 / Published online: 23 October 2009
Springer-Verlag 2009

Abstract Sixty-eight patients were clinically evaluated

preoperatively, 3, 5, 7, 9 months, 1 and 2 years after ACL
reconstruction, 34 with patellar tendon graft, 34 with
hamstring graft. Outcome regarding graft choice and
anterior knee laxity (P = 0.04) was in favour of patellar
tendon graft. Hamstring graft led to a larger laxity, 2.4 mm
compared with patellar tendon graft, 1.3 mm at 1 year and
2.5 mm and 1.5 mm, respectively, at 2 years (P = 0.05).
There was a significant difference in rotational knee stability in favour of the patellar tendon graft at all test
occasions but 9 months. A general effect regarding graft
choice and muscle torque was found at 90/s for quadriceps
(P = 0.03) and hamstrings (P B 0.0001) and at 230/s for
hamstrings (P B 0.0001). No treatment effect regarding
graft choice and one-leg hop test, postural sway or knee
function was found. No group differences in anterior knee
pain were found at any of the test occasions but 2 years in
favour of hamstring graft compared to patellar tendon graft
(P = 0.04). Patellar tendon graft resulted in higher activity
level than hamstring graft at all test occasions but 1 year

A. Heijne (&)
Division of Physiotherapy, Department of Neurobiology,
Care Sciences and Society, Karolinska Institutet,
23100, 141 86 Huddinge, Sweden
e-mail: annette.heijne@ki.se
A. Heijne  S. Werner
Department of Molecular Medicine and Surgery,
Stockholm Sports Trauma Research Center,
Karolinska Institutet, Stockholm, Sweden
S. Werner
Capio Artro Clinic, Stockholm, Sweden
S. Werner
Sofiahemmet, Stockholm, Sweden

(P = 0.01). Patellar tendon ACL reconstruction led to

more stable knees with less anterior knee laxity and less
rotational instability than hamstring ACL reconstruction.
Hamstring graft patients had not reached preoperative level
in hamstring torque even 2 years after ACL reconstruction.
Athletes with patellar tendon graft returned to sports earlier
and at a higher level than those with hamstring graft.
Keywords ACL rehabilitation  Knee laxity 
Muscle strength  Subjective outcome

Introduction
Anterior cruciate ligament (ACL) injury is one of the most
serious injuries related to sports performance. This type of
knee injury is especially common in athletes participating
in so called pivoting sports that are characterised to put
high demands on knee joint stability. No consensus exists
about the treatment, although most orthopaedic surgeons
suggest that the ruptured ACL in athletes should be treated
with reconstructive surgery when considering return to
pivoting sports. During recent years it has been a shift from
the use of patellar tendon to hamstring tendons in terms of
graft choice for ACL reconstruction. However, the graft
used for an optimal clinical outcome still remains controversial [12, 31]. When it comes to rehabilitation most
authors have described the use of a similar rehabilitation
programme irrespective of graft [2, 6, 8, 10, 18]. It should
be pointed out though, that evidence is still lacking concerning how the different grafts influence physical outcome
over time. Therefore, the aim of the present investigation
was to evaluate both a short and a 2-year follow-up of
physical outcome in patients who have received the same
rehabilitation after ACL reconstruction with either patellar

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Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

tendon or hamstring tendon grafts. It was hypothesised that,

irrespective of graft choice, the patients were fully recovered in terms of hamstring muscle torque at the 2-year
follow-up.

Materials and methods

Patients
Between 1999 and 2005, 80 ACL injured patients, 42
males and 38 females met the inclusion criteria and were
involved in preoperative physiotherapy at a Sport Rehabilitation Clinic. Six males and six females declined to
participate due to lack of time (n = 8), no ACL reconstruction was performed (n = 3), and transferral to another
city (n = 1). Sixty-eight patients, 36 males and 32 females
were finally included as participants in the study (Table 1).
The inclusion criteria were age between 16 and 50 years
and a symptom free contra-lateral knee. Patients with a
medial or lateral meniscus tear and/or a medial collateral
ligament injury grade I, where surgical repair was not
indicated, were also included. The exclusion criteria were
injuries other than the above mentioned, uncorrected
vision, a medial collateral ligament injury grade II or III,
meniscus lesions suitable for fixation, and patients operated
with patellar tendon or hamstring grafts harvested from
their contra-lateral leg.

Table 1 Demographic data for patients with patellar tendon bone-tobone (PTBTB) graft (N = 34) and patients with hamstring graft
(N = 34)
PTBTB graft
(n = 34)

Hamstring
graft (n = 34)

Males/females

22/12

14/20

Age, years (M, SD)

29 (7)

30 (9)

Height, m (M, SD)

1.75 (0.08)

1.73 (0.09)

Weight, kg (M, SD)

75.1 (10.1)

72.4 (11.9)

BMI, kg/m2 (M, SD)

24.3 (2.4)

24.2 (2.9)

Injured leg left/right

15/19

13/21

Median time between injury

and surgery, months
(lower and upper quartile)

7.8 (512)

8.5 (518)

Semitendinosus graft alone (n)

23

Semitendinosus ? gracilis graft (n)

11

Medial meniscus injury

11

Lateral meniscus injury

Patella cartilage damage

Tibia cartilage damage

Femur cartilage damage

Medial collateral ligament injury

123

Twenty experienced orthopaedic surgeons performed

the ACL reconstructions with patellar tendon or hamstring
grafts. Four patients, who had undergone reconstruction
with hamstring graft, and four patients, who had undergone
reconstruction with patellar tendon graft, had to undergo
another arthroscopy during the follow-up period. The reasons for this were; removal of a shaver blade that was lost
during the index operation (n = 1), extraction of a loose
body in the knee joint (n = 1), pain in the knee joint
(n = 3), trauma, suspected graft rupture (n = 1), removal
of cyclops syndrome (n = 1), resection of extensive scar
tissues in the knee joint (n = 1).
Group randomization and rehabilitation
This study is a follow-up study based on an earlier publication [17] aimed to investigate whether early introduction
of closed kinetic chain exercises for quadriceps influenced
early outcome after ACL reconstruction with either patellar
tendon graft or hamstring graft. In that study, stratified for
gender, the patients were postoperatively randomised into
four different groups in terms of rehabilitation. At the first
postoperative rehabilitation session each patient with
patellar tendon graft or hamstring graft, respectively, was
asked to choose one out of 50 closed envelopes (25 for
males and 25 for females) for group randomization. At the
end of the study there were three envelopes left for males
and 13 for females with patellar tendon graft and 11
envelopes left for males and five for females with hamstring graft. The reason for using more envelopes than was
calculated by the power analysis was that patients included
late in the study should have the same chance to be randomised to either of the groups. The earlier reported difference in terms of rehabilitation for each type of graft
could not be seen when analysing the data reported in the
present study. Therefore, only the outcome based on type
of graft is reported here.
All patients started the standardised postoperative
rehabilitation programme within 1 week after surgery at the
same outpatient clinic. Supervised physiotherapy was
performed 23 times a week as long as the patient and the
physiotherapist considered it necessary. The median number of training sessions was 51 (18109) for the patients
reconstructed with patellar tendon graft and 50 (1393) for
the patients reconstructed with hamstring graft. The rehabilitation protocol consisted of joint and muscle flexibility
exercises, balance- and coordination training and strength
training focusing mainly on the thigh muscles. One group
of patients with patellar tendon ACL reconstruction started
with open kinetic chain quadriceps exercises 4 weeks
postoperatively, while another group started 12 weeks
postoperatively. The same goes for patients operated on
with hamstring tendon grafts. No brace was used during the

Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

rehabilitation period. Immediate weight bearing according

to tolerance was allowed after surgery. Based on muscle
strength, balance/coordination and functional performance
the patients were allowed to return to active, competitive
sports 6 months postoperatively or later depending on the
functional capacity. Full description of the rehabilitation
protocol can be seen in an earlier publication [17]. Ten
experienced physiotherapists were involved in the
rehabilitation.
Postoperative ACL ruptures
One female patient sustained a re-rupture (hamstring tendon graft) of her reconstructed knee and one male patient
sustained a new ACL injury of his contra-lateral knee
within 2 years after the first ACL reconstruction. These
injuries are included in the statistical calculations using the
mixed model statistical method.
Evaluation
All patients were evaluated by two experienced independent examiners within 4 weeks prior to surgery as well as 3,
5, 7, 9 months, 1 and 2 (mean 24.7 months, SD 1.2) years
after surgery. None of these two examiners were involved
in the rehabilitation. The same examiner followed the same
patient at all his/her test occasions and both examiners
were blinded for type of rehabilitation (early or late start of
open kinetic chain quadriceps training), but not for type of
reconstruction.
The evaluation consisted of the methods presented
below. All measurements at each test occasion were carried
out in the following order.

807

eccentric muscle torques of the quadriceps and hamstring

muscle groups at 90/s as well as 230/s and within 90
10 of knee flexion, always starting with the contra-lateral
uninjured leg. At the 3-month test occasion, thigh muscle
torque was only tested within 9040 of knee flexion.
One-leg hop test for distance
The one-leg hop test for distance was used for functional
hop performance [5]. The patient was standing on one leg
and instructed to jump straight ahead as far as possible.
Three trials were performed on both legs, and the patient
decided which leg to start with [5]. The best trial of each
leg was chosen for statistical calculations. The ratio
between the legs was calculated and reported in percent.
Postural sway
Kinesthetic Ability Trainer 2000 (KAT 2000TM) (BREG
Inc., CA, USA) was used for measuring balance/postural
sway when standing on one leg. KAT 2000 has been
found to be reliable for testing groups of individuals
[14]. The measurements were performed during standardised conditions by having the patient standing barefoot on one leg, with that knee as well as the knee of the
free leg flexed approximately 30, and the arms crossed
in front of the chest. Three tests, 20 s each, were performed on both legs starting with the uninjured contralateral leg. The distance between the centres of the board
to centre of pressure was measured in arbitral units. The
best trial (least postural sway) was used for statistical
calculations.
Anterior knee pain

Anterior knee laxity

Anterior tibial displacement relative to the femur was
measured bilaterally at approximately 20 of knee flexion
with the KT-1000 arthrometer (MEDmetric, Corp., San
Diego, CA, USA) at max manual. The difference in displacement between the operated and the contra-lateral
uninjured knee was expressed in millimetres [7, 30].
Pivot shift
The pivot shift test was used to control possible rotational
instability and recorded according to the International Knee
Documentation Committee (IKDC) [15, 16].
Thigh muscle torques
The Kin-Com dynamometer (Chattex Corp., Chattanoga,
TN, USA) [9] was used for measuring concentric and

An anterior knee pain (AKP) score modified from an earlier publication [29] was used to evaluate possible AKP.
This score has been revised, adjusted and specified for
possible AKP in ACL injured patients (Werner S, unpublished data). The score consists of 8 subgroups; pain,
occurrence of pain, walking upstairs, walking downstairs,
sitting with flexed knee [30 min, squatting, kneeling and
arretationscatching. 50 points is the maximum score
which is equal to no AKP. The sensitivity of the score was
studied on patients with ACL injuries, patients after
patellar tendon ACL reconstruction, patients after hamstring tendon ACL reconstructions, patients with postoperative meniscus lesions, and uninjured controls. With
regards to the total score there was a significant difference
between uninjured controls and ACL injured patients
(P = 0.0001). A testretest procedure indicated good
reliability with an intra-class correlation (ICC) of 0.97 of
the total score (Werner S, unpublished data).

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Knee injury osteoarthritis outcome score (KOOS)

The Knee injury osteoarthritis outcome score (KOOS) was
used to assess the patients opinion about his/her knee
function and possible associated problems. [23, 24]. KOOS
consists of 42 items, grouped into five separate subscales;
(1) pain, (2) other symptoms, (3) function in daily living
(ADL), (4) function in sport and recreation (Sport/Rec) and
(5) knee-related quality of life (QoL).

Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

choice, the effect of concentric and eccentric muscle

actions, a time effect and the effect of whether the ACL
reconstruction was performed in the left or right knee.
Further, the analyses for anterior knee laxity included a
covariance structure called compound symmetry.
In situations in which a significant general treatment
effect was observed, planned pair-wise comparisons were
used. To adjust the significant levels of the planned comparisons, a Bonferroni correction was made. SAS PROC
MIXED was used for these analyses.

Tegner activity scale

Statistical methods
Prior to the study a power analysis was made based on
anterior knee laxity. A difference of 1.5 mm side-to-side
difference in anterior knee laxity of the reconstructed knee
estimated a sample size of 15 patients in each group with
80% power when P B 0.05. The power analysis was made
as a two-group repeated measures ANOVA (Greenhouse-Geisser correction) in the nQuery 4.0. Due to the
multiple methods used in this study, more patients were
included.
The present study has a longitudinal design with two
parallel treatment groups. The demographic data of the
patients and the training volume are presented in means
and standard deviations or medians and lower and upper
quartiles.
In terms of testing the AKP score for reliability and
sensitivity, repeatability was measured by an ICC. Group
differences were analysed by one-way ANOVA and post
hoc comparisons were made according to the Tukey honestly difference test. If the distributions were severely
skewed, repeatability was measured by MannWhitney
U-test and Kendall0 s rank order correlation and group
differences by KruskalWallis test and MannWhitney
U-test. The data from the AKP score, pivot shift and
KOOS were considered as non-parametric data and Mann
Whitney U-test was used when calculating the results.
In order to compare the ratio in thigh muscle torques,
differences in anterior knee laxity and differences in postural sway between the operated knee and the uninjured
contra-lateral knee over time, a mixed effect model analysis was used. These analyses included testing for graft

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Results
Anterior knee laxity
A general treatment effect was found in terms of graft
choice and laxity (P = 0.04). For the 3, 5, 7 and 9 months
follow-up no general treatment effect was found. At the
1-year follow-up a statistical significant difference
(P = 0.03), in laxity was found between the operated and
the uninjured knee for the patellar tendon graft, 1.3 mm
(SD 0.4) and for the hamstring graft, 2.4 mm (SD 0.3). At
the 2-year follow-up it was 1.5 mm (SD 0.3) and 2.5 mm
(SD 0.4), respectively (P = 0.05) (Fig. 1).

3.5

Patellar tendon graft

Hamstring graft
3.0

anterior knee laxity (mm)

The Tegner activity scale [28], which describes the

patients type as well as level of activity (010) was used.
A high score means that the patient participates in sports
that place high demands on knee joint stability.
The present investigation has received approval from the
Ethics Committee at the Karolinska Institutet, Dnr 99-091.
All patients granted their informed consent prior to
participation.

2.5

2.0

1.5

1.0

0.5

0.0
3 months
7 months
1 year
5 months
9 months
2 years

Fig. 1 Anterior knee laxity (mm) (mean and CI) between the
healthy- and the ACL-reconstructed knee at 3, 5, 7, 9 months,
1 and 2 year follow-up for patients after patellar tendon ACLreconstruction (n = 34) and hamstring ACL-reconstruction (n = 34)

Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

Pivot shift
A general treatment effect was found in terms of graft
choice and rotational knee stability (P \ 0.05). A statistical
significant difference between the patellar tendon graft and
the hamstring graft, in favour of the patellar tendon ACL
reconstruction, was seen at all follow-ups except for the
9-months follow-up (n.s.) (Table 2).
Muscle torques
A general treatment effect in terms of graft choice and
muscle torque over time was found for quadriceps torque at
90/s (P = 0.03), hamstring torque at 90/s (P \ 0.001)
and hamstring torque at 230/s (P \ 0.001), but not for
quadriceps torque at 230/s (n.s.) (Figs. 2, 3, 4, 5).
One-leg hop test for distance
No general treatment effect in terms of graft choice and
one-leg hop test for distance was found (n.s.) (Table 3).
Postural sway
The preoperative values were used as a covariate in the
present analysis. There were no significant group differences in terms of postural sway over time (n.s.).
Anterior knee pain
No significant group differences in terms of AKP were
found preoperatively or at any of the follow-ups except for
the 2-year follow-up. A significant difference, in favour of
the hamstring tendon graft, N = 30, 45.5 (2850), compared to patellar tendon graft, N = 30, 42 (2650) was
observed at the 2-year follow-up (P = 0.04).
Knee injury osteoarthritis outcome score (KOOS)
No significant group differences regarding knee function
and quality of life as determined with KOOS were found
over time in neither of the subscales and therefore all
patients were analysed together as one unit. A significant
improvement irrespective of graft used was seen over time
in all subscales (P \ 0.001) (Fig. 6).
Tegner activity scale
No significant group differences in terms of activity level
were found preoperatively or at 5, 7, 9 months or 2 years
after ACL reconstruction. A significant difference, in
favour of the patellar tendon graft (7, range 110 versus 5,
range 28) was seen at the 1-year follow-up (P = 0.01).

809
Table 2 Numbers and percentage (%) of assessed patients with Pivot
Shift preoperatively and at 3, 5, 7 and 9 months as well as 1 and
2 years postoperatively according to the IKDC classification
(1 = none, 2 = ?(glide), 3 = ??(clunk) and 4 = ???(gross) after
patellar tendon or hamstring ACL-reconstruction

Assessed patients
Pre-op
1
2
3
4
Assessed patients
3 Months
1
2
3
4
Assessed patients
5 Months
1
2
3
4
Assessed patients
7 Months
1
2
3
4
Assessed patients
9 Months
1
2
3
4
Assessed patients
1 Year
1
2
3
4
Assessed patients
2 Years
1
2
3
4

Patellar tendon
graft
n (%)

Hamstring
graft
n (%)

P value

(n):

30

32

12 (38)
18 (56)
2 (6)
30

0.61

(n):

2 (6.5)
12 (40)
14 (47)
2 (6.5)
32

10 (33)
18 (60)
2 (7)

29

0.05

(n):

20 (62.5)
11 (34.5)
1 (3)

26

8 (27.5)
20 (69)
1 (3.5)

27

0.04

(n):

16 (61.5)
9 (34.5)
1 (4)

27

11 (40.5)
14 (52)
2 (7.5)

26

0.01

(n):

21 (78)
6 (22)

22

8 (31)
16 (61.5)
2 (7.5)

30

0.37

(n):

11 (50)
9 (41)
2 (9)

31

9 (30)
15 (50)
6 (20)

29

0.008

(n):

19 (61)
12 (39)

30
17 (57)
10 (33)
3 (10)

8 (27.5)
13 (44.5)
7 (24)
1

0.02

The P values for the whole model is \0.05. The P values for each
follow-up are shown in the last column

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Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

1.1

1.2
Patellar tendon graft

Patellar tendon graft

Hamstring graft

Hamstring graft

1.1

Hamstrings Ratio (%) 90 deg/s

Quadriceps ratio (%) 90 deg/s

1.0

0.9

0.8

0.7

0.6

0.5

0.4

1.0

0.9

0.8

0.7

0.6

0.5

Preop
5 months
9 months
2 years
3 months
7 months
1 year

Fig. 2 The quadriceps muscle ratio at the velocity 90/s, (ACLreconstructed knee/healthy knee) (mean and CI) preoperatively, at 3,
5, 7, 9 months and 1 and 2 year follow-up for patients after patellar
tendon ACL-reconstruction (n = 34) and hamstring ACL-reconstruction (n = 34). *At the 3-month follow-up the test was performed
within 9040 of knee flexion

5 months
9 months
2 years
3 months
7 months
1 year

Fig. 4 The hamstring muscle ratio at the velocity 90/s, (ACLreconstructed knee/healthy knee) (mean and CI) preoperatively, at 3,
5, 7, 9 months and 1- and 2-year follow-up for patients after patellar
tendon ACL-reconstruction (n = 34) and hamstring ACL-reconstruction (n = 34)

1.3

1.1

Patellar tendon graft

Patellar tendon graft

Hamstring graft

Hamstring graft
1.0

1.2

Hamstrings ratio (%) 230 deg/s

Quadriceps ratio (%) 230 deg/s

preop

0.9

0.8

0.7

1.1

1.0

0.9

0.8

0.7

0.6

Preop

7 months
1 year
5 months
9 months
2 years

Fig. 3 The quadriceps muscle ratio at the velocity 230/s, (ACLreconstructed knee/healthy knee) (mean and CI) preoperatively, at 5,
7, 9 months and 1- and 2-year follow-up for patients after patellar
tendon ACL-reconstruction (n = 34) and hamstring ACL-reconstruction (n = 34)

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0.6

preop

7 months
1 year
5 months
9 months
2 years

Fig. 5 The hamstrings muscle ratio at the velocity 230/s, (ACLreconstructed knee/healthy knee) (mean and CI) preoperatively, at 5,
7, 9 months and 1- and 2-year follow-up for patients after with
patellar tendon ACL-reconstruction (n = 34) and hamstring ACLreconstruction (n = 34)

Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

811

Table 3 Descriptive data from the one-leg hop test (mean and SD)
and number of patients tested at each follow-up for patients reconstructed with patellar tendon graft and patients reconstructed with
hamstring grafts. The ratio between the reconstructed knee/healthy
knee is presented
PTBTB graft

Hamstring graft

7-Month follow-up

0.85 (0.14) N = 22

0.91 (0.10) N = 16

9-Month follow-up

0.91 (0.11) N = 23

0.88 (0.14) N = 25

1-Year follow-up

0.91 (0.09) N = 29

0.94 (0.08) N = 29

2-Year follow-up

0.94 (0.07) N = 28

0.99 (0.07) N = 25

100
90
80
70
60
50
40
30

Preop ACL-reconstruction

20

12 months postoperative

10

24 months postoperative

L
O

t/R
or

ec

L
AD

Sp

Sy

pt

Pa

om

in

Fig. 6 Knee function according to knee injury osteoarthritis outcome

score (KOOS) for the patients preoperatively (N = 68), 12 months
(N = 64) and 24 months (N = 61) after ACL-reconstruction. QOL
quality of life, ADL activity of daily living

Discussion
The principal and most interesting finding of the present
study was that ACL reconstruction with hamstring graft led
to somewhat greater laxity by time when compared with
patellar tendon ACL reconstruction. Another finding was
that 2 years after ACL reconstruction patients operated on
with hamstring graft showed both significantly lower
quadriceps and hamstrings strength ratio in comparison
with patients operated on with patellar tendon graft as well
as when compared with their own preoperative values.
From a surgical point of view a successful ACL
reconstruction depends on several factors, for example the
knee flexion angle and the graft of tensioning at the time of
fixation. In a recent published review [3] it was reported
that no randomised controlled studies have been performed
in order to determine the most effective amount of tension
to apply to hamstring grafts. The patients in the present
study were operated on with the same technique by
several orthopaedic surgeons but with similar experience of
ACL reconstructions. However, the initial graft tension
applied during fixation is not known. Whether the number
of different orthopaedic surgeons has any influence on the
result or whether it plays any significant role for functional

knee joint stability could be questionable, though. A further

limitation of this study is that the choice of graft was not
randomised for, but based on the surgeons preferences, for
instance experience and patient-related factors such as
gender or level of activity.
Moreover, this study was stratified for gender resulting
in similar amount of males and females in each group,
which could have influenced the results since it has been
reported [11] that females, reconstructed with hamstring
tendon graft, shows a significantly greater knee laxity
compared to males. Laxdal et al. [18] reported no significant differences in terms of knee laxity in males operated
on with patellar tendon graft or hamstring graft. Unfortunately, the cohort in the present study was too small to
allow gender-related comparisons. The difference in anterior knee laxity and rotational stability between grafts
found in the present study might be judged as small and
questionable from a clinical point of view. But it could be
speculated that in some sports with heavy demands on
rotational and anterior stability and even a small side-toside difference in anterior knee laxity might play an
important role. Furthermore, it has theoretically been proposed that excessive tibial rotation will lead to osteoarthritis [26]. In a recent publication, Liden et al. [19]
reported degenerative changes (Fairbank system) of the
knee joint in 74% of the patients who had undergone an
ACL reconstruction with either patellar tendon graft or
hamstring tendon grafts. It has been reported previously
that patellar tendon is a more stiff tissue than hamstring
tendon [21]. It is probable that this is one explanation for
the somewhat higher side-to-side difference in anterior
knee laxity and greater knee instability according to the
pivot shift test after hamstring ACL reconstruction when
compared with patellar tendon ACL reconstruction.
Thigh muscle strength is often reported to be one of the
cornerstones of importance after ACL reconstruction [22].
The quadriceps muscle dynamically stabilises the knee
joint in most functional activities but hamstrings play an
important role in terms of shear forces by preventing the
tibia from sliding anteriorly relative to the femur. After
hamstring ACL reconstruction it took less than 1 year to
reach preoperative level of quadriceps torques and not even
2 years after reconstruction they had reached preoperative
levels of hamstring torques as evaluated with isokinetic
dynamometry at both angular velocities used. After patellar
tendon ACL reconstruction it took only 5 months to reach
preoperative level of hamstring torques but 2 years to reach
preoperative level of quadriceps torques irrespective of
angular velocities used. Whether preoperative values is
sufficient enough when planning to return to sport can be
discussed since the patients usually have been injured for a
time and therefore probably have less then normal strength.
In terms of muscle qualities there are reasons to believe

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that muscle power is the most important strength variable

in sports [27]. Therefore, it may be considered a limitation
in the present study that this type of muscle quality evaluation was not carried out. However, the results from our
study is in agreement with a recently published study [1],
reporting results from muscle power strength test in patient
operated on with either patellar tendon or hamstring tendon
grafts. Ageberg et al. [1] reported that patients operated on
with hamstring tendon grafts had a significantly lower limb
symmetry index in knee flexion power compared to those
patients operated on with patellar tendon graft. This means
that the hamstring muscles are considerably more vulnerable than the quadriceps muscles after hamstring ACL
reconstruction. Therefore, these findings suggest that extra
effort should be placed on strengthening the hamstrings
after ACL reconstruction with hamstring graft. It also
means that a safe return to sport earlier than 2 years after
ACL reconstruction may be questionable since the hamstring muscles are regarded to be the major dynamic stabilisers in terms of shear forces in the knee joint [25].
There were no group differences with respect to the oneleg hop test for distance and postural sway. This indicates
that these tests may not be sensitive enough to detect differences in performance due to graft choice. Earlier studies
have pointed out the importance of using a battery of
functional tests in order to improve sensitivity [13, 20].
Furthermore, a standardised test design by measuring the
patient during both non-fatigued and fatigued conditions
have been proposed in order to receive a reliable result of
clinical relevance [4].
Feller and Webster [10] reported significantly more
AKP after patellar tendon ACL reconstruction than hamstring tendon ACL reconstruction as measured with Visual
Analogue Scale (VAS). Clinical suggestions have arosen
that this might be an important factor in deciding which
graft is the most appropriate one for a particular patient.
We did not find any group differences in terms of AKP
preoperatively and at all postoperative test occasions
except at the 2 years follow-up, when patients with hamstring tendon ACL reconstructions reported somewhat less
AKP than patients with patellar tendon ACL reconstructions. However, this small group difference most likely
does not have any clinical relevance meaning that the risk
of developing AKP after ACL reconstruction is probably
not a reason for the choice of graft.
No significant group differences were seen over time
regarding knee function and quality of life according to
KOOS. These findings show that patellar tendon and
hamstring tendon grafts are equally good in terms of subjective knee evaluation of knee function and quality of life.
It should be pointed out, though, that irrespective of graft
choice for ACL reconstruction the patients did not reported
themselves as fully symptom free as judged by all the

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Knee Surg Sports Traumatol Arthrosc (2010) 18:805813

different subgroups of KOOS. This is observed especially

when it comes to sports and recreation as well as quality of
life. However, this may be the natural course after ACL
reconstruction.
Participation in sports according to Tegner showed a
significant group difference of two levels in favour of the
patellar tendon group at the 1-year test occasion. However,
no differences between groups were found at the other test
occasions. One can therefore speculate that patients with
patellar tendon ACL reconstructions are able to return to
sports earlier and at a higher level than those operated on
with hamstring tendon grafts. This result is likely to be of
special interest when dealing with athletes. The somewhat
smaller anterior knee laxity and/or the better knee joint
stability as determined with the pivot shift test in patients
with patellar tendon ACL reconstruction compared to
patients with hamstring tendon graft may play a role for
this group in returning to sport. A stable knee joint probably leads to less fear of and better sports performance than
a more unstable knee joint.
During the last decade, there has been a shift from
patellar tendon graft to hamstring tendon grafts for ACL
reconstruction. A non-evidence-based unreflective imitation of the rehabilitation protocol used after ACL reconstruction with patellar tendon graft can be seen in clinical
practise. In light of the present study it is suggested that
extra effort should be placed on strengthening of the
hamstring muscles after hamstring ACL reconstruction.
This might lead not only to improved muscle strength and
muscle balance but to some extent prevent graft elongation.

Conclusion
Patellar tendon graft leads to more stable knees with less
anterior laxity and less pivot shift. Patients with hamstring
ACL reconstruction need more hamstring strengthening
exercises. Some of our data indicate that patients operated
on with hamstring grafts might need another and slower
rehabilitation protocol focusing more on hamstring
strength than those with patellar tendon graft. Athletic
patients with patellar tendon ACL reconstructions returned
to sports earlier and at a higher level than those operated on
with hamstring tendon grafts.
Acknowledgments Funding for this study was provided, in part, by
grants from the Swedish National Center for Research in Sports. We
also gratefully thank all the patients for sharing their time with us.

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