Hamstring Graft Research Articles

The Use of Five-Strand Hamstring Autograft to Increase the Graft Size in Anterior Cruciate Ligament Reconstruction—A Prospective Cohort Study With Satisfactory Early Clinical Results

To report on the outcomes of using 5-strand hamstring autograft to increase the graft size for anterior cruciate ligament (ACL) reconstruction and to determine whether the clinical results are comparable to using conventional 4-strand graft. A prospective cohort study of patients with arthroscopic-assisted single-bundle ACL reconstruction using hamstring autograft from January 2019 to June2021.The patients were prospectively recruited to undergo ACL reconstruction with either 5-strand hamstring graft (group A) or 4-strand hamstring graft (group B). In total, 45 patients were included into the study. The mean diameter of the final graft was 8.9 ± 0.6 cm in the 5-strand group and 7.5 ± 0.8 cm in the 4-strand group (P < .001). Four-strand graft diameter measurements were taken intraoperatively in the 5-strand group before preparation of the 5-strand graft. The mean graft diameter of the 4-strand grafts was similar in both groups: 7.3 ± 0.3 mm in group A and 7.5 ± 0.8 mm in group B (P= .72). There was no statistically significant difference between the 2 groups of patients in terms of the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS) Symptoms, KOOS Pain, KOOS Activities of Daily Living, KOOS Sports and KOOS Quality of Life scores. There were no postoperative complications of wound infection in both groups of patients. There was one case of graft rupture (4.8%) in the 4-strand group, which required revision reconstruction with patellar tendon graft 9 months postoperatively. There was no case of graft rupture in the 5-strand group (P= .29). The 5-strand hamstring graft technique provides a graft with significantly larger graft diameter than the quadrupled graft technique, with satisfactory short- to medium-term outcomes. The 5-strand graft is therefore a useful technique to increase the graft size when faced with the problem of small hamstring graft. Level II, prospective cohort study.

A Comparative Randomized Clinical Study of Arthroscopic Anterior Cruciate Ligament Reconstruction with Patellar Tendon and Hamstring Tendon Autologous Grafts

Aim: To determine and compare differences in the results following arthroscopic anterior cruciate ligament reconstruction using patellar-tendon-bone (PTB) auto-grafts and hamstrings tendon auto-grafts. Study design: Randomized controlled trial. Place and duration: Department of Orthopedic Surgery, Shaikh Zayed Hospital Lahore from July 2019 to July 2021. Methodology: This prospective study included 72 of total patients with clinical diagnosis of having anterior cruciate ligament (ACL) tear who did not have activities like a healthy person and wished to maintain a level of activity as it was before injury. Institutional ethical committee granted approval and a written informed consent was taken. Two groups of study population (patellar tendon and hamstring tendon) were formed. Lottery method was used for randomization of patients. Arthroscopic ACL reconstruction was done according to their respective groups. Patients of patellar tendon group (n=36) and hamstring tendon group (n=36) were under examination for 4 to 5 days and to grant 0 to 900 movement, knee brace was locked. Patients were questioned about their activities on follow up visits. Results: No significant difference amongst patients of two groups was noted.14 patients (38.9%) with PTB graft were unable to kneel on their knee as compared to 12 patients (33%) with hamstrings graft. Patients with BTB graft had similar difficulty in bending their knee as compared to the patients of the other group. Conclusion: Patients from PTB graft group showed comparable results as compared to the hamstrings group in terms of strenuous activity, highest level of activity, rising from a chair and kneeling and squatting on functional outcomes. Keywords: Anterior Cruciate Ligament, Patellar Auto-graft, Hamstring Auto-graft, Bone Graft

Clinical and arthroscopic outcomes of single-bundle anterior cruciate ligament reconstruction using autologous hamstrings augmented with ligament augmentation and reconstruction systems compared with four-strand hamstring tendon grafts alone.

To compare the clinical, radiological, and second-look arthroscopic outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (hamstring group) either without augmentation or with ligament augmentation and reconstruction system (LARS) augmentation (LARS augmentation group). From January 2018 to December 2019, patients who underwent ACL reconstruction were included. Patient-reported outcome measures (PROMs) were undertaken pre-operatively and at three, six, 12, and 24months post-operatively. Arthroscopic evaluation was performed focusing on the morphology of the graft based on graft tension, graft tear, and synovial coverage. A total of 178 consecutive patients received single-bundle ACL reconstruction, 89 patients in each group, and 20 patients were lost to follow-up in the first twoyears. At the threemonth follow-up, the LARS augmentation group had significantly higher Lysholm scores, IKDC scores, and KOS-ADLS scores than the hamstring group (P < 0.001). At the three, six and 12-month follow-ups, there were significantly higher Tegner scores and ACL-RSI scores in the LARS augmentation group than in the hamstring group (P < 0.05). At the three and sixmonth follow-ups, the LARS augmentation group had significantly higher rates of return to sports and return to sports at their preinjury level (P < 0.05). There were no between-group differences in other outcomes, including arthroscopic outcomes, graft signal intensity, post-operative complications or rerupture rates. Autologous hamstring augmented with the LARS augmentation technique provides good and realistic clinical and functional results during the early post-operative period with high levels of satisfaction of patients, including participation in sports and physical activity, and high rates of return to sports at the preinjury level, without any apparent complications compared with hamstring ACL reconstruction alone. No increases in complication, reinjury rates, or increased lateral laxity were observed at the 12-month or 24-month follow-up.

Femoral fixation methods for hamstring graft in anterior cruciate ligament reconstruction: A network meta-analysis of controlled clinical trials.

ObjectiveTo compare the clinical effectiveness of cortical button (CB), cross-pin (CP) and compression with interference screws (IS) fixation techniques in anterior cruciate ligament (ACL) reconstruction using hamstring graft.MethodsStudies were systematically retrieved from PubMed, Embase, Cochrane Library and Web of Science up to May 20, 2021. Primary outcomes were KT-1000 assessment, International Knee Documentation Committee (IKDC) score A or B, Lachman’s test, pivot-shift test, visual analogue scale (VAS) score, Lysholm score, Tegner score, and Cincinnati Knee Score. Secondary outcomes included reconstruction failures and synovitis. League tables, rank probabilities and forest plots were drawn for efficacy comparison.ResultsTwenty-six controlled clinical trials (CCTs) with 1,824 patients undergoing ACL reconstruction with hamstring graft were included. No significant differences were found among CB, CP and IS fixation methods regarding the 10 outcomes. For KT-1000 assessment, IKDC score A or B, Lachman’s test, VAS score and pivot-shift test, CP had the greatest probability of becoming the best method, and IS may be the suboptimal method in 4 out of these 5 outcomes except pivot-shift test.ConclusionsCP, CB and IS fixations have comparable clinical performance, while CP fixation is most likely to be the optimum fixation technique for hamstring graft in ACL reconstruction. Future larger-sample studies of high quality comparing these techniques in more clinical outcomes are required.

Comparison of biomechanical analysis of four different tibial tunnel fixations in a bovine model

BackgroundTo determine the ideal fixation technique for an ACL reconstruction with a hamstring graft, multiple studies have been undertaken to define the initial biomechanical properties of tibial fixation. PurposeThe aim of this study was to compare the biomechanical properties of tibial fixation methods by creating single or hybrid systems. MethodsBovine tibias and forefoot digital extensor tendons were prepared with four different tibial anterior cruciate ligament fixation methods and compared biomechanically. Fixation materials included polyethylene Ultrabraid high-strength sutures, Biosure interference screws (Smith and Nephew, Memphis, TN, USA), staples (Smith and Nephew, Richards Regular Fixation Staples without Spikes, Memphis, TN, USA), and knotless suture anchors (Multifix-S PEEK) (Smith and Nephew, Memphis, TN, USA). Four groups (n = 5 specimens) were established – group I: single fixation with interference screws; group II: single fixation with knotless anchors; group III: hybrid fixation with interference screws and staples; group IV: hybrid fixation with interference screws and knotless anchors. Each specimen underwent evaluations for cyclic displacement, cyclic stiffness, initial loading strength, ultimate failure load, pull-out displacement, and pull-out stiffness. ResultsAll specimens completed cyclic loading and load-to-failure. The cyclic displacement in group II, which had a single fixation, indicated significantly greater elongation compared with the other groups (P = 0.002). The hybrid systems were more rigid than the single systems in terms of cyclic stiffness, and no statistically significant difference was observed between the hybrid systems (P = 0.461). Group IV was significantly superior in terms of the ultimate failure load (P = 0.004). No statistically significant differences were noted between the groups for pull-out displacement or pull-out stiffness. ConclusionSingle fixation with bioscrews as an in-tunnel tibia fixation method was as successful as hybrid systems. Multifix-S PEEK knotless suture anchors, which can be combined with bioscrews, can be a superior fixation alternative due to its flexibility and ultimate failure load values.

Five-Stranded Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

Background: Hamstring tendon (HT) autograft for anterior cruciate ligament (ACL) reconstruction has shown equivalent graft failure rates to bone-patellar-tendon-bone (BTB) with decreased prevalence of anterior knee pain. It should be noted that young athletes, particularly females athletes, may have increased graft failure rates with HT versus BTB. Additionally, HT graft diameters &lt;8 mm have shown worse patient-reported outcomes and higher graft failure rates. Five-strand HT autograft offers a method to increase graft size without utilization of allograft tissue or synthetic material. Indications: This presentation describes the technique for 5-strand HT autograft reconstruction of the ACL. Tips and tricks on graft prep, tunnel placement, tunnel depth, and avoiding pitfalls in surgery are provided. Technique Description: Gracilis and semitendinosus tendon harvest is performed through an L-shaped flap of sartorial fascia. If the 4-strand configuration is &lt;8 mm, the semitendinosus is tripled for a 5-strand configuration. Graft is attached to a 15-mm fixed-length button construct for femoral fixation. The tibial tunnel is typically drilled with the guide through the accessory anteromedial portal. Independent femoral tunnel drilling is then performed via the accessory anteromedial tunnel with the knee in hyperflexion, using an offset guide to aid in tunnel placement. Femoral tunnel is initially reamed to depth of 25 mm and then drilled through the far cortex with a 4.5-mm drill to allow for suspensory fixation. Total length to the lateral cortex is measured and reaming of the tunnel is performed to achieve a 5- to 7-mm difference between total tunnel length to the lateral cortex and reamed tunnel length, assuring room for the button to flip on the femoral cortex. Tibial fixation is achieved by interference fixation versus tying the free suture limbs over a post with a washer. Results: Recent studies show the HT autograft to have similar re-rupture rates for ACL reconstruction compared with other autograft options. Additionally, this option has low donor-site morbidity and has demonstrated significant less anterior knee pain and kneeling pain postoperatively. Discussion/Conclusion: ACL reconstruction with 5-strand HT autograft has shown to be an effective method to increase the graft diameter with low rates of donor-site morbidity.

Predicting autologous hamstring graft diameter and finding reliable measurement levels in the Zhuang population using preoperative ultrasonography.

Purpose: To evaluate the feasibility of using ultrasonography to preoperatively predict the autologous hamstring graft diameter for anterior cruciate ligament (ACL) reconstruction in the Zhuang population and determine a reliable measurement level using ultrasound. Methods: Twenty-four Zhuang patients who were scheduled for ACL reconstruction using four-strand semitendinosus tendon (ST) and gracilis tendon (G) (4S-STG) autografts were included in this study. Ultrasonographic examinations of the ST and the G on the damaged side were conducted before the operation. We recorded the transverse diameter (TD), anterior–posterior diameter (APD), cross-sectional area (CSA), and perimeter (P) of the tendons. The measurements were obtained from two levels of the tendons: the widest point of the medial femoral epicondyle (level 1) and the myotendinous junction of the sartorius (level 2). We also calculated the combined (ST + G) TD, APD, CSA, and p values. Then, we obtained the intraoperative measurements. The correlation between the ultrasonic and intraoperative measurements was analyzed, and the advantages of the ultrasonic measurements at the two different levels were compared. Results: When we measured at level 1, we found that part of the ultrasonic measurements were correlated with intraoperative measurements. The preoperative CSA of the G (P-GCSA) can be used to distinguish a 4S-STG autograft diameter of ≥8 mm (p < 0.01, mean difference = 3.7). The area under the P-GCSA curve was 0.801 (p < 0.05). A P-GCSA of 8.5 mm2 could be used to predict a 4S-STG autograft diameter of ≥8 mm with a sensitivity of 61.1% and specificity of 83.3%. However, there was no correlation between the ultrasonic and intraoperative measurements at level 2. Conclusion: Preoperative ultrasound can be used to predict the sufficient diameter of 4S-STG autografts when considering patients from Zhuang who are undergoing ACL reconstruction. The ultrasonic measurement should be obtained at the widest point of the medial femoral epicondyle.

High revision arthroscopy rate after ACL reconstruction in men's professional team sports.

The study analysed unique data on anterior cruciate ligament (ACL) injuries among German professional male team sports over five consecutive seasons with the aim of improving medical outcomes in the future. Sport-specific differences in injury occurrence, concomitant injuries, timing of ACL reconstruction, graft type selection and short-term complications were examined. This retrospective study analysed trauma insurance data on all complete ACL tears from players with at least one competitive match appearance in the two highest divisions of German male basketball, ice hockey, football and handball. Each complete ACL tear registered by clubs or physicians between the 2014/15 and 2018/19 seasons with the German statutory accidental insurance for professional athletes (VBG) as part of occupational accident reporting was included. In total, 189 out of 7517 players (2.5%) sustained an ACL injury, mainly in handball (n = 82; 43.4%) and football (n = 72; 38.1%) followed by ice hockey (n = 20; 10.6%) and basketball (n = 15; 7.9%).Seventeen players (9.0%) also sustained a second ACL injury. Thus, 206 ACL injuries were included in the analysis. The overall match incidence of ACL injuries was 0.5 per 1000h and was highest in handballs (1.1 injuries per 1000h). A total of 70.4% of ACL injuries involved concomitant injury to other knee structures, and 29.6% were isolated ACL injuries. The highest rate of isolated ACL injuries was seen in ice hockey (42.9%). All ACL injuries, except for one career-ending injury, required surgery. In the four analysed team sports, hamstring tendons (71.4%) were the most commonly used grafts for ACL reconstruction; football had the highest percentage of alternative grafts (48.7%). During rehabilitation, 22.9% of all surgically treated ACL injuries (n = 205) required at least two surgical interventions, and 15.6% required revision arthroscopy. The main cause of revision arthroscopy (n = 32; 50.0%) was range-of-motion deficit due to arthrofibrosis or cyclops formation. The present study shows an overall high rate of revision arthroscopy after ACLR (15.6%), which should encourage surgeons and therapists to evaluate their treatment and rehabilitation strategies in this specific subpopulation. Hamstring tendon grafts are most commonly used for ACL reconstruction but have the highest revision and infection rates. Handball shows the highest ACL injury risk of the four evaluated professional team sports. Concomitant injuries occur in the majority of cases, with the highest share of isolated ACL injuries occurring in ice hockey. Level III.

Five-Strand Hamstring Grafts are Biomechanically Comparable to Four-Strand Grafts and Offer Greater Diameter for Anterior Cruciate Ligament Reconstruction

PurposeThe purpose of this study was to compare the biomechanics of 4-strand and 5-strand hamstring constructs for anterior cruciate ligament grafts.MethodsThirty-six human cadaveric hamstring grafts were tested in 3 different conditions: (1) graft femoral fixation complex, (2) graft femoral and tibial fixation (GFTF) complex using a human model, and (3) GFTF complex using a porcine model. Grafts were tested on a tensile testing machine. Four-stranded grafts served as the control group, and 5-stranded grafts served as the experimental group. Cyclic elongation, ultimate load to failure, stiffness, and diameter of the grafts were analyzed.ResultsAverage 4-strand graft diameter was 7.96 mm compared to 9.32 mm for the 5-strand graft (P = .00017). Average stiffness of grafts ≥8 mm was 105.04 N/mm compared to 85.05 N/mm for grafts <8 mm (P = .04988). There was a positive correlation between graft diameter and stiffness (13.4 N/mm per every 1 mm increase in diameter, r2 value of 13.1%, and F-significance of 0.02778). There were no significant differences in terms of ultimate load to failure, cyclic elongation, or stiffness between the experimental groups.ConclusionFive-strand hamstring grafts offer greater diameter and are biomechanically comparable to 4-strand equivalents at time 0. Grafts >8 mm offer significantly greater stiffness compared to grafts sized <8 mm. There is a weak positive correlation between graft diameter and stiffness.Clinical RelevanceA potential drawback to hamstring grafts is their variability in size. Five-strand hamstring grafts provide increased diameter in comparison to 4-strand equivalents and might be used when quadrupled graft diameter is <8 mm.

Single versus double hamstring tendon graft in anterior cruciate ligament reconstruction in the paediatric patient: a single-blind randomised controlled trial study protocol

IntroductionThere is currently no clear indication in the literature regarding a single or double hamstring tendon (single bundle) autograft for anterior cruciate ligament (ACL) reconstruction in the paediatric patient. The...

Paper 23: The Impact of Graft Choice on Return to Sport Testing After Adolescent ACL Reconstruction

Objectives:The number of anterior cruciate ligament (ACL) injuries and reconstructions observed in the adolescent population continues to rise. While the use of quadriceps tendon autograft has increased in popularity in this population, there remains no consensus on the ideal graft for pediatric ACL reconstruction. The objective of this study was to compare three commonly used ACL graft types with respect to i) performance on return to sport assessments and ii) timing to clearance for return to sports in an adolescent population.Methods:All patients, less than or equal to 19 years of age, who underwent reconstruction for ACL tears between 2016 and 2020 at a large, urban, academic institution were identified. Graft choice was made in a shared decision-making model with patient, parents, and surgeon. Patient demographics, laterality, graft type, time from surgery to clearance, number of physical therapy (PT) visits, and presence of concomitant meniscus injuries were collected from the electronic medical record. At a minimum of 6 months postoperatively, patients completed a formal return to sport test (RTS) including isometric strength assessments, Y- balance testing, and hop testing. Treatment cohorts based on graft type were compared with respect to RTS performance and timing to clearance. Associations between patient demographics and return to sport timing and performance were also assessed. Clearance for return to sport was determined by the treating surgeon with limb symmetry index of 90% on RTS as the goal for clearance.Results:A total of 110 adolescents, 44 female (40%), with a mean age of 16.3 years (SD, 1.7; range, 10-19) met our inclusion criteria (Table 1). Average time to first RTS assessment was 280 days (9.3 months) and average time to clearance was 371 days (12.2 months) after surgery. ACL grafts included 58 (52.7%) hamstring autografts, 26 (23.6%) bone-patellar tendon-bone (BPTB) autografts, 21 (19.1%) bone quadriceps (BQT) autografts, and 5 (4.6%) iliotibial band (ITB) autografts. ITB patients were younger on average (12.5 years old) than those receiving hamstring, BPTB or BQT grafts. There were no significant differences between groups with respect to laterality, number of physical therapy visits, or rate of concurrent meniscus surgery.Patients receiving BQT grafts were more likely to be cleared within 1 year of surgery compared to hamstring graft patients (82.4% vs. 39.6%, p=0.002) and had similar rates of clearance within 1 year compared to BPTB patients (82.4% vs. 65.2%, p=0.230). Patients with BQT and BPTB grafts both demonstrated significantly better hamstring strength symmetry compared to hamstring graft patients (5.8% strength deficit compared to healthy side vs. 1.3% vs. 29.3%, p<0.001) (Table 2). There were no differences in quadriceps strength or hop test asymmetry between graft types. Multivariate regression with age, gender, and number of PT sessions included as covariates demonstrated that hamstring graft choice was associated with decreased odds of clearance at 1 year.Conclusions:In this study of 110 adolescent ACL reconstruction patients who underwent return to sport evaluations, we found no significant difference between BPTB and BQT autografts with respect to RTS performance and time to clearance. Hamstring autograft was associated with significantly worse hamstring strength asymmetry and significantly lower rates of clearance within 1 year. Concurrent meniscus surgery, age, gender, and number of PT sessions completed prior to RTS evaluation were not significantly associated with timing of clearance or performance on the RTS assessment.Table 1.Patient Demographics and Surgical CharacteristicsTable 2.Patient Demographics and Performance by 3 Common Graft Types

Functional outcome of anatomical reconstruction of anterior cruciate ligament with hamstring graft: A one year hospital based - observational study

Background: Knee injuries are more common in the modern era due to increase in the road traffic accidents and more involvement in sports related activities by young people. Anterior cruciate ligament is the often injured ligament around knee joint. Anterior cruciate ligament has a pivot role in function and stability of the knee joint, being the primary stabilizer preventing the anterior translation of tibia over femur. Arthroscopic anterior cruciate ligament reconstruction has become the gold standard in the management of these injuries.Objective of the study: To assess the functional outcome of anatomical reconstruction of ACL with quadrupled hamstring graft.Materials and Methods: Patients with post traumatic anterior cruciate ligament injury admitted to the Department of Orthopaedics at the Kle's Dr. Prabhakar Kore Hospital and Medical Research Centre and Charitable Hospital, Belagavi in between 1st January 2019 to 31st December 2019, over a period of one year – hospital based observational study.Results: The study group comprised of 30 patients. In our study the most common mode of injury was found to be Road traffic accident followed by sports. Abundant of the patients were in the age group of 18-25yrs. In our study 13 patients had isolated ACL injury, 11 pts had medial meniscus injury, 4 patients had lateral meniscus injury and 2 patients had both the meniscus injured. It is found that 57% of them associated meniscal injury. Functional outcome was assessed using LYSHOLM and GILLQUIST SCORE. At the end of 9th month follow up 80% of the patient had excellent score which were 57% at the 3rd month. 13% of patient had good score at the end of 9th month and 7% of patient had fair score. None of the patient had poor score.Conclusion: Anatomical reconstruction of ACL with quadrupled hamstring graft gives better clinical outcomes. The advantage of using hamstring graft are reduced donor site morbidity and less anterior knee pain in long term follow up. It has better subjective and objective functional outcome with low graft rejection or failure rate.

Persistent quadriceps muscle atrophy after anterior cruciate ligament reconstruction is associated with alterations in exercise-induced myokine production

PurposePersistent quadriceps muscle atrophy is observed in a subset of patients following anterior cruciate ligament reconstruction (ACLR) despite the completion of comprehensive rehabilitation. Critically, quadriceps muscle atrophy correlates with muscle weakness and quadriceps strength deficits. The aim of this study was to examine the effect of resistance exercise on myokine levels and muscle atrophy status in ACLR patients with persistent quadriceps muscle atrophy. MethodsSixteen participants between the ages of 18–39 with a Tegner score of >6 and who had undergone ACLR with hamstring graft were recruited for the study. Quadriceps muscle thicknesses were ascertained by ultrasonography and isokinetic strength assessments were made prior to commencing a single bout of resistance exercise training (RET). Blood samples were taken before and after RET and assayed for myokine expression. Self-reported activity level and knee function questionnaires were completed and recorded. ResultsClustering by quadriceps muscle size measurements created a non-atrophy group of 9 subjects and an atrophy group of 7 subjects. There were no significant between-group differences in anthropometric measurements, time post operation and knee function questionnaires, but the atrophic group comprised of patients with lower pre-injury sporting levels. The atrophy group exhibited significant lower side-to-side muscle thickness ratios and a decreasing trend in quadriceps strength deficits. Serum brain-derived neurotrophic factor (BDNF) was up-regulated in response to RET in non-atrophy group, but a negative fold change was detected in the atrophy group. ConclusionThe dysregulation in myokines plays an important role in patients failing to regain muscle mass after ACLR leading to persistent quadriceps muscle atrophy, which may potentiate greater strength deficits and poor functional recovery.

Evaluation of Functional Outcome Following Transportal Arthroscopic Anterior Cruciate Ligament Reconstruction using Quadrupled Hamstring Graft

Introduction: The anterior cruciate ligament (ACL) has an important role in preserving the function and stability of the knee joint, and it prevents anterior translation of the tibia. The ACL is the most commonly injured structure of the knee following posttraumatic and sports-related injuries. The treatment of modality for ACL insufficiency was arthroscopic ACL reconstruction. In this study, we followed the transportal approach for ACL reconstruction using a Quadrupled Hamstring graft, and we reported the functional outcome of ACL reconstruction at a minimum follow-up of 6 months. Materials and Methods: This was a prospective outcome study conducted on 32 patients who met the inclusion and exclusion criteria. All patients in this study underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft through transportal technique. The graft was fixed with an endobutton on the femoral side and an interference screw on the tibial side. Patients were assessed for the functional outcome for a minimum of 6 months using the Tegner-Lysholm knee scoring system. Results: The mean age of the patient was 27 years. The majority of involved patients were males. The left side (77.14%) was involved more than the right side (22.86%). The most common cause of ACL injury in this study was road traffic accidents. Preoperative Tegner-Lysholm scores were 20 (62.5%) patients had poor and 12 (37.5%) patients had fair scores. Post-operatively, at 6 months follow-up, 27 patients had excellent, four patients had good scores, and one patient had a fair score. There was a significant improvement in the Tenger-Lysholm scoring system after 6 months of follow-up when compared to preoperatively. Three patients had knee pain and thigh muscle wasting (2 – 3 cm) during follow-up. Conclusions: Transportal arthroscopic ACL reconstruction using Quadrupled Hamstring graft gives excellent functional outcome and knee kinematics.

Comparative study of the modified transtibial technique and the transportal technique in anterior cruciate ligament reconstruction.

This study sought to compare the efficacy of the modified transtibial (TT) technique and the transportal (TP) technique in arthroscopic anterior cruciate ligament (ACL) reconstruction. This study retrospectively analyzed the clinical data of 74 patients (74 knees) who underwent ACL reconstruction using a single bundle of autologous hamstring tendon graft from October 2013 to September 2017. Forty-one knees were reconstructed using the TT technique (the TT group), and 33 were reconstructed using the TP technique (the TP group). There was no statistically significant difference between the two groups (P>0.05) in terms of age, sex, follow-up time, time from injury to operation, left and right knees, body mass index, and preoperative International Knee Documentation Committee (IKDC) score, Tegner Activity score (Tegner score), Lysholm score, Lachman test results, and Pivot-Shift test results. The incisions in both groups were healed by first intention, and no early postoperative complications occurred. All patients attended follow-up appointments. The TT group had a follow-up period of 24-46 months (average follow-up time: 27.3 months). The TT group had a follow-up period of 24-38 months (average follow-up time: 26.3 months). Two years after surgery, the IKDC, Lysholm, and Tegner scores of the two groups were significantly improved compared to those before surgery (P<0.05), and there was no statistically significant difference between the two groups in relation to these scores (P>0.05). There was also no statistically significant difference in the Lachman and Pivot-Shift test results between the two groups (P>0.05). Both the TT and TP techniques provide satisfactory efficacy in ACL reconstruction.

Poster 252: Revision Risk of Hamstring Versus Hybrid Graft in Anterior Cruciate Ligament Reconstruction

Objectives:Hamstring autograft (HA) is a commonly used graft for anterior cruciate ligament reconstruction (ACLR). Hamstring tendon harvest can occasionally result in a small diameter graft, leaving the surgeon with several options. One option is to augment the hamstring graft with allograft tendon to increase the combined graft diameter forming a hybrid graft (HG). Inconsistent results of HG reconstructions have been reported, with some studies reporting worse outcomes for HG while others showing no difference between the two types of grafts. However, these studies have small sample sizes or are of an older patient population. The purpose of our study was to compare the revision rates of HA versus HG grafts in a young patient population.Methods:We conducted a retrospective cohort study of prospectively collected data from our integrated healthcare system’s ACLR Registry. Patients <25 years of age with a primary, isolated ACLR performed between 2005-2020 were identified; those with prior surgery in the index knee, double bundle, and infections (septic revisions) were excluded. The exposure of interest was graft type and diameter size, including <8mm HA and >8mm HG. Hybrid graft was defined as a hamstring tendon augmented with an allograft tendon to increase the graft diameter. Grafts with unknown diameter sizes and other graft types were excluded. A secondary analysis examined 7mm and 7.5mm HA vs >8mm HG. Propensity score-weighted Cox proportional hazard regression was used to evaluate the risk of aseptic revision during follow-up. Propensity score weights were calculated prior to evaluation of the outcome using multivariable logistic regression analysis and included age, sex, body mass index, race/ethnicity, femoral fixation, tibial fixation, femoral tunnel method, and activity at injury. Hazard ratios (HR) and 95% confidence intervals (CI) are presented. A P<0.05 was considered statistically significant.Results:The final cohort comprised 1,945 ACLR (548 were >8mm HG and 1397 were <8mm HA, including 651 with 7mm diameters and 672 with 7.5mm). At 8-years follow-up, the crude cumulative aseptic revision probability for >8mm HG was 9.1%, while <8mm HA was 10.9% (Figure 1); corresponding cumulative probabilities for 7mm and 7.5mm HA were 11.1% and 11.2% respectively. After adjustment with propensity score weighting, we failed to observe a difference in aseptic revision risk for <8mm HA compared with >8mm HG (HR=1.15, 95% CI = 0.72-1.82, p=0.56) (Table 1). Similarly, no difference was observed for 7mm HA (HR= 1.23, 95% CI=0.71-2.11, p=0.46) and 7.5mm HA (HR=1.16, 95% CI =0.74-1.82, p=0.52) compared to HG.Conclusions:In our cohort study of 1,945 patients, we failed to detect a statistical difference in the risk of aseptic revision between a HA < 8mm and a HG > 8mm. The clinical significance is that augmentation of HA with an allograft does not appear to decrease the risk of aseptic revision and may not be necessary. Future studies should be conducted to confirm these findings.Figure 1.Cumulative Incidence of Aseptic Revision by Graft Type/Diameter Size.Table 1.Crude Cumulative Revision Probability And Adjusted Risk After Aclr By Graft Type/Diameter Size.

The role of transpaterllar viewing portal in anterior cruciate ligament reconstruction

Background Anatomical anterior cruciate ligament (ACL) reconstruction aims to place the ACL graft within its anatomical orientation. Malposition of the graft especially on the femoral side is the persisting complication of ACL reconstruction. The lateral femoral condyle can be visualized by the transpatellar viewing portal to place the graft in a more anatomical position. Aim To evaluate the result of arthroscopic ACL reconstruction using transpatellar portal viewing. Patients and methods This study included 31 patients in whom the torn ACL will be reconstructed arthroscopically using the transpatellar portal viewing and AAMP at Tanta University Hospital with a period of 6 months of follow-up. Results Transpatellar portal technique has been used to create the femoral tunnel independently to the tibial tunnel for more anatomic position that lead to improvement in rotational stability, without increased complexity. The central portal offers the advantage of more anatomical ACL reconstruction with improved femoral footprint placement. Transpatellar portal provides an excellent visualization of the femoral footprint and therefore reduces the incidence of improper tunnel positioning during ACL reconstruction without significant complications. Conclusion Anatomical insertion of the hamstring graft using the transpatellar portal viewing can offer an excellent restore of the anterior knee stability.

CORRELATION OF HAMSTRING GRAFT SIZE WITH ANTHROPOMETRIC MEASUREMENTS IN PATIENTS UNDERGOING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION AT CHITWAN MEDICAL COLLEGE

Background: Injury to Anterior Cruciate Ligament (ACL) commonly occurs in knee injury usually requiring surgical intervention. Use of hamstring autograft for ACL reconstruction (ACLR) is commonly practiced. Many factors govern the selection of graft. Literature lacks studies showing correlation between anthropometric measurements of patients and the size of hamstring tendon graft in ACLR in Nepalese population. This study aimed to correlate anthropometric measurements to diameter and length of graft obtained. Methods: Cross sectional study was carried out from 17th April 2021 to 15th March 2022 and approved by CMC-IRC (Ref: CMC-IRC/078/079-094) and evaluating patients who have undergone surgery in Anthropometric measurements along with thigh length and circumference was measured pre-operatively. Length and diameter of prepared graft was measured intraoperatively before insertion. Forty (n=40) patients of mixed age, sex and ethnicity undergoing Arthroscopic ACLR were included. Statistical analysis was done to find correlation between anthropometric measurements and graft size harvested. Purposive sampling technique was used. Data collection was done in proforma. Data entry was done in Excel and and analysis was done in SPSS version 21. Results: Statistical analyses showed strong positive correlation between patient’s thigh length and graft diameter. Height shows positive correlation with graft length and diameter. Weight shows positive correlation with graft length. There was very low correlation of other variables with graft diameter and length which were statistically insignificant. Conclusions: Positive correlation factors (thigh length, height and weight) can be utilized to anticipate good quality graft and can be used during ACLR.

Bone plug fixation in anterior cruciate ligament reconstruction: A clinical and radiological assessment of graft-tunnel integration

BackgroundThe decision regarding graft choice and fixation in anterior cruciate ligament (ACL) reconstruction remains controversial. Free cylindrical bone plugs have been used successfully as graft fixation method. However, some concerns continue to exist regarding how well these plugs integrate with the bony walls of the tunnel. The aim of this study was to assess osteo-integration of free cylindrical bone plugs and to evaluate its effect on the clinical outcomes of the procedure. MethodsFrom January 2015 to December 2017, 30 patients (21–40 years old) with torn ACL were operated on and followed up for 24 months after surgery. All patients were assessed clinically (International Knee Documentation Committee score (IKDC) and Tegner–Lysholm knee scoring system), instrumentally (KT 1000 and Rolimeter), and radiologically (X-ray, computed tomography and magnetic resonance imaging). Young active patients with torn ACL were included while those with previous ligamentous injury and/or surgery were excluded. ResultsAll bone grafts showed solid bone healing after 6 months of surgery; incorporation was ‘good to excellent’ (tibial side: 66.6%; femoral side: 86.6%). There was no correlation between age or time interval and graft incorporation. Positive correlation was shown between tibial and femoral graft incorporation within the same patient. Only one patient was abnormal in our final objective IKDC scores (graded C). The mean side-to-side difference with KT 1000 and Rolimeter was 1.9 and 1.8, respectively. ConclusionFree cylindrical bone plugs could be used safely for hamstring tendon graft fixation; it enhances graft tunnel integration within the first 6 months and yields comparable clinical outcomes whilst avoiding the potential hazards of foreign hardware implants.

Does an Adjustable-Loop Device Loosen following ACL Reconstruction with a Hamstring Graft? A Retrospective Study with a Follow-Up of Two Years.

Arthroscopic anatomic anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for an ACL tear and requires the use of fixed or adjustable-loop devices to fix a femoral-side graft. Although the adjustable mechanism is designed to provide one-way tensioning, there is a concern that the adjustable loop will loosen and lengthen during cyclic loads, creating graft laxity. The present paper is a retrospective study of patients who underwent ACLR with the fixation of a hamstring graft with an adjustable loop on the femoral side from November 2016 to October 2018. The knee’s functional outcome was evaluated using an International Knee Documentation Committee (IKDC) score, Lysholm score, Lachman test, and pivot shift test. The patients were assessed preoperatively and finally postoperatively after two years of surgery. Thirty-two patients were analyzed. Significant improvement was obtained in the final clinical outcome of the patients. Twenty-seven patients (84.4%) were Lachman negative, and twenty-eight patients (87.5%) were pivot shift test negative, the mean Lysholm score was 96.91, and the IKDC score was 91.47 (p < 0.001). There was no infection, graft failure, or flexion restriction. Arthroscopic ACLR with an adjustable-loop suspensory device is a successful fixation method for femoral-side graft fixation and offers a similar functional outcome as with fixed-loop devices.