Quadrupled Hamstring Autograft Research Articles

Anterior cruciate ligament reconstruction using quadruple strand hamstring autografts and biodegradable femoral cross-pin: Results of a single surgeon in a district general hospital

Anterior cruciate ligament reconstruction using quadruple strand hamstring autografts and biodegradable femoral cross-pin: Results of a single surgeon in a district general hospital

Knee stiffness following anterior cruciate ligament reconstruction: The incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction

We reviewed 100 patients retrospectively following primary ACL reconstruction with quadruple hamstring autografts to evaluate the incidence and factors associated with postoperative stiffness. Stiffness was defined as any loss of motion using the contra-lateral leg as a control. The median delay between injury and operation was 15 months. The incidence of stiffness was 12% at 6 months post-reconstruction. Both incomplete attendance at physiotherapy ( p < 0.005) and previous knee surgery ( p < 0.005) were the strongest predictors of the stiffness. Anterior knee pain was also associated with the stiffness ( p < 0.029). Factors that failed to show a significant association with the stiffness included associated MCL sprain at injury ( p = 0.32), post-injury stiffness ( p = 1.00) and concomitant menisectomy at reconstruction ( p = 0.54). Timing of surgery also did not appear to influence the onset of stiffness (median delays: 29 months for stiff patients; 14 months for non-stiff patients). The rate of stiffness fell to 5% at 12 months postreconstruction, without operative intervention.

Prospective Comparison of Auto and Allograft Hamstring Tendon Constructs for ACL Reconstruction

Although allograft use for primary anterior cruciate ligament reconstruction has continued to increase during the last 10 years, concerns remain regarding the long-term function of allografts (primarily that they may stretch with time) and clinical efficacy compared with autograft tendons. We attempted to address these issues by prospectively comparing identical quadrupled hamstring autografts with allograft constructs for primary anterior cruciate ligament reconstruction in patients with a minimum followup of 3 years. Eighty-four patients (37 with autografts and 47 with allografts) were enrolled; the mean followup was 52 +/- 11 months for the autograft group and 48 +/- 8 months for the allograft group. Outcome measurements included objective and subjective International Knee Documentation Committee scores, Lysholm scores, Tegner activity scales, and KT-1000 arthrometer measurements. The two cohorts were similar in average age, acute or chronic nature of the anterior cruciate ligament rupture, and incidence of concomitant meniscal surgeries. At final followup, we found no difference in terms of Tegner, Lysholm, KT-1000, or International Knee Documentation Committee scores. Five anterior cruciate ligament reconstructions failed: three in the autograft group and two in the allograft group. Our data suggest laxity is not increased in allograft tendons compared with autografts and clinical outcome scores 3 to 6 years after surgery are similar. Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Muscle Strength Evaluations after ACL Reconstruction

The quadriceps and hamstring muscle strengths of 16 patients operated using a bone-patellar tendon-bone (BTB) autograft and 32 patients operated using a quadruple hamstring autograft for an arthroscopic anterior cruciate ligament (ACL) reconstruction were analyzed 4- to 7-years postoperatively. Standardized isokinetic testing, a clinical evaluation and instrumented assessment of knee laxity were done. The findings showed no significant strength deficits between the patients in the BTB and Hamstring groups and the deficits were, in general, small. The quadriceps and hamstring muscle strengths were better in patients with a longer than shorter follow-up and stable knees had less knee flexion torque deficit than unstable knees. Strength deficit was associated with lower Lysholm knee scores. The findings of this study showed that the muscle strengths of the operated limb had a positive association with the functional outcome of the knee in the long-term and support the use of active rehabilitation after ACL reconstruction.

Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up

This study prospectively evaluates the outcomes at a minimum 4-year follow-up after PCL reconstruction using quadruple hamstring tendon autograft with an arthroscopic double fixation technique. During 1996-1999, hamstring tendon autograft graft has been used in 57 patients. Data from 52 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of posterior drawer test and posterior sag sign with MRI image confirmation. Twelve knees had combined posterior and posterolateral instability, which were simultaneously reconstructed. Clinical assessments included Lysholm knee score, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented test, thigh muscle assessment, and radiographic evaluation. The mean Lysholm score was 54 (40-65) and 91 (65-100) points (P<0.01) before and after surgery. Thirty (58%) patients could return to moderate or strenuous activity. The evaluation of AP translation has been performed with KT-1000. The average posterior displacement measured with KT-1000 was 11.69+/-2.01 mm preoperatively and 3.45+/-2.04 mm postoperatively. Forty-two (81%) patients demonstrated ligament laxity of less than 5 mm. Forty-two (81%) patients were rated as normal or nearly normal based on IKDC scores. Forty-six (88%) patients achieved a minimum of 80% recovery of extensor strength and 44 (85%) patients achieved a minimum of 80% recovery of flexor strength. Statistically significant differences existed in thigh girth, extensor strength, and flexor strength before and after reconstruction. Arthroscopic reconstruction for PCL with four-strand hamstring tendon graft produced satisfactory results. The semitendinosus and gracilis tendon graft is adequate in graft size, technically easier to perform and more reproducible, and had a satisfactory result.

Bone tunnel enlargement after ACL reconstruction using autologous hamstring tendons: a CT study

To evaluate prospectively the increase in the size of the tibial and femoral bone tunnel following arthroscopic anterior cruciate ligament (ACL) reconstruction with quadrupled-hamstring autograft. Twenty-five consecutive patients underwent arthroscopic ACL reconstruction with quadrupled-hamstring autograft. Preoperative clinical evaluation was performed using the Lysholm knee score, Tegner activity level, and International Knee Documentation Committee forms and a KT-1000 arthrometer (side to side). Computed tomography (CT) of the femoral and tibial tunnel was performed on the day after operation in all cases and at mean follow-up of 10 months (range 9-11 months). All of the clinical evaluation scales performed showed an overall improvement. The postoperative anterior laxity difference was <3 mm in 16 patients (70%) and 3-5 mm in seven patients (30%). The mean average femoral tunnel diameter increased significantly (3%) from 9.04+/-0.05 mm postoperatively to 9.3+/-0.8 mm at 10 months; tibial tunnel increased significantly (11%) from 9.03+/-0.04 mm to 10+/-0.8 mm. There were no statistically significant differences between tunnel enlargement, clinical results, and arthrometer evaluation. The rate of tunnel widening observed in this study seems to be lower than that reported in previous studies that used different techniques. We conclude that an anatomical surgical technique and a less aggressive rehabilitation process influenced the amount of tunnel enlargement after ACL reconstruction with doubled hamstrings.

Reconstruction of Isolated Posterior Cruciate Ligament Injuries: A Clinical Comparison of the Transtibial and Tibial Inlay Techniques

To compare the clinical and stress radiologic results of posterior cruciate ligament (PCL) reconstruction using the transtibial tunnel technique and tibial inlay technique. Retrospective case series. Patients who had received isolated PCL reconstruction without combined ligamentous reconstruction and who also had a minimum 2-year follow-up were included in the study. The transtibial tunnel technique with quadrupled hamstring autograft group (group A) was composed of 21 knees and the tibial inlay technique with bone-patellar tendon-bone autograft group (group B) of 22 knees. We compared the 2 groups with regard to Lysholm knee scores, Tegner activity scores, posterior draw tests at 90 degrees flexion, and radiologic stability of the knees by using a Telos device (Austin & Associates, Fallston, MD). The Lysholm knee scores showed a significant improvement from 55.3 points preoperatively to 91.5 at the final follow-up in group A and from 51.7 preoperatively to 93.5 at the final follow-up in group B. However, intergroup differences were not significantly different (P = .259). Activity levels, as determined using the Tegner scoring system, also showed significant improvements at the final follow-up in both groups, but again, this was not significantly different (P = .264). On the posterior drawer test at the final follow-up, normal or grade I laxity was observed in 19 patients in group A and in 20 patients in group B. By instrumented posterior laxity testing, mean side-to-side differences were significantly improved from 12.3 mm preoperatively to 3.7 mm at the final follow-up in group A and from 11.0 mm to 3.3 mm in group B, but without significance (P = .607). The transtibial tunnel and tibial inlay techniques produced relatively good clinical and stress radiologic results, and no significant differences were identified between the 2 techniques. Therefore, we suggest that the transtibial tunnel and tibial inlay techniques are both satisfactory PCL reconstruction procedures. Level III.

The incidence and significance of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation

Purpose: The purpose of this study was to evaluate the amount of femoral tunnel widening that occurred after anterior cruciate ligament reconstruction using quadrupled hamstring autografts and to determine the clinical significance of any such tunnel enlargement. Type of Study: Retrospective clinical analysis. Methods: Twenty-nine patients who had undergone reconstruction of a torn anterior cruciate ligament with quadrupled hamstring autograft and cross pin femoral fixation were evaluated to determine the incidence and significance of postoperative femoral tunnel widening. A single surgeon performed all procedures, and average follow-up was 18.4 months (range, 12 to 31.5 months). All patients underwent flexion posteroanterior and lateral radiographs, an examination for determination of an International Knee Documentation Committee (IKDC) rating, had KT-1000 data collected, and completed Lysholm and Knee Outcome Survey functional questionnaires. Femoral tunnels were clearly seen in 27 patients. The tunnel diameters were measured at the opening of the tunnel, at the widest part of the tunnel, and just proximal to the cross pin. The amount of tunnel widening for each patient was then compared with the individual’s KT-1000 data, IKDC rating, and Lysholm and knee outcome survey scores to assess correlation. Results: Four different tunnel morphologies were noted, with the linear type being the most common. The widening at the greatest tunnel diameter was 65.5% on average. Side-to-side KT-1000 differences averaged 1.04 mm at 30 lb, and 1.10 mm at manual maximum. Eleven patients had IKDC overall ratings of normal, 13 had ratings that were nearly normal, and 2 had abnormal. Average Lysholm and knee outcome survey scores were 92.6 and 93.9, respectively. A significant correlation was found only between F2 and F3 widening with Lysholm scores. However, the significance was eliminated with removal of 2 outliers. Conclusions: The exact etiology of postoperative anterior cruciate ligament tunnel widening remains unknown. The present study reveals that significant tunnel widening occurs with quadrupled hamstring autografts and femoral cross pin fixation. However, the widening does not appear to have a significant effect on postoperative ligament laxity or functional knee scores, at least in the short term.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: pp 470–476

Tibial Tunnel Lysis Following Anterior Cruciate Ligament Reconstruction: A Randomized Prospective Study of Two Different Surgical Techniques (SS-07)

Tibial tunnel enlargement is a common occurrence following multiple techniques of anterior cruciate ligament reconstruction. The etiology is felt to be multifactorial: biological and mechanical. Biologic mechanisms include the presence and persistence of synovial fluid and catabolic cytokines in the tibial tunnel. We hypothesized that retaining the native ACL stump may provide a “stopper” effect, preventing synovial fluid leakage into the tibial tunnel, and this assists in preventing tunnel enlargement from occurring. The purpose of this randomized prospective MRI study was to determine the presence of synovial fluid in the tibial tunnel following two different surgical techniques of ACL reconstruction using a quadrupled hamstring autograft. Materials and Methods: We randomized 20 patients having ACL reconstruction with a quadrupled hamstring autograft into two groups. Group A consisted of 11 patients who retained the native ACL stump. Group B consisted of 9 patients who had the native ACL stump completely resected. All patients underwent MRI scans at an average of 45 days postoperatively in order to determine tunnel measurements and to evaluate for the presence of synovial fluid in the tunnel. Results: Four patients in each group demonstrated fluid in the tibial tunnel on a postoperative MRI. Ten of the 20 patients had 2 postoperative MRIs at an average of 34 and 68 days postoperatively. None of these patients demonstrated fluid in the tibial tunnel on the first MRI, but three demonstrated fluid in the tibial tunnel on the second MRI. There was an increase in diameter of the tibial tunnel in 5 patients between the first and second MRI. Of the 5 which demonstrated increasing tunnel diameter, 2 had fluid present in the tunnel, both of which were in group B. Discussion: The cause of tunnel enlargement following ACL reconstruction is multifactorial. Synovial fluid presence within the tunnel may be associated with enlargement. In our study, native ACL stump preservation did not appear to limit synovial fluid leakage into the tunnel.

Proprioception of the knee before and after anterior cruciate ligament reconstruction

Purpose: The purpose of this study was to determine, first, if there is measurable deficit in proprioception in an anterior cruciate ligament (ACL)-deficient knee, either compared to the contralateral knee or external controls; second, if this deficit, if present, improves after ACL reconstruction; and third, if improvement occurs, what the time course of improvement is. Type of Study: Prospective cohort study. Methods: Patients undergoing ACL reconstruction at the University of Chicago, demonstrating a full and painless range of motion and no other knee ligament injury or history of previous knee surgery, were eligible. Twenty-six patients, with an average age of 25 years (range, 16 to 48) were enrolled. Average time from injury to reconstruction was 8 weeks. The patients' contralateral knee served as an internal control, and 26 age-matched and gender-matched healthy volunteers were enrolled as an external control group. ACL reconstructions were performed using a single-incision technique with either bone–patellar tendon–bone or quadrupled hamstring autograft. They were allowed immediate weightbearing as tolerated and participated in a standardized rehabilitation program, with the goal of returning to sport at approximately 6 months. Proprioception testing was carried out using an electrogoniometer, in a seated position. Joint position sense (JPS) and threshold to detection of passive motion (TDPM) were measured preoperatively and at 3 and 6 weeks and 3 and 6 months postoperatively. Results: Mean KT-2000 values 6 months postoperatively were 1.38 mm (±2). Modified Lysholm score improved significantly ( P < .01). Calculated r values were 0.65 for JPS and 0.96 for TDPM. No significant differences in postoperative proprioception were found between hamstring and patellar tendon grafts or among patients with meniscus injury, meniscus repair, or chondral injury. Preoperatively, the mean TDPM in both the injured and contralateral knees was significantly higher (worse) than in the external control knees ( P = .008; P = .016). Evaluation of changes in proprioception from preoperative to 6 months postoperative showed significant improvement in both injured and contralateral knees ( P = .04; P = .01). At 6-month follow-up, there was no significant difference from controls. Conclusions: TDPM was a more reliable method than JPS for testing proprioception before and after ACL reconstruction in this study. Bilateral deficits in knee joint proprioception (TDPM) were documented after unilateral ACL injury. Reconstruction of a mechanical restraint (ACL graft) was believed to have a significantly positive impact on early and progressive improvement in proprioception.

Arthroscopic reconstruction of the posterior cruciate ligament: A comparison of quadriceps tendon autograft and quadruple hamstring tendon graft

Purpose: Considerable controversies remain on the graft choice and fixation methods in the posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare, at minimal 2-year follow-up, the outcomes of PCL reconstruction between using quadriceps tendon autograft and using quadruple hamstring tendon autograft. Type of Study: Case series. Methods: All patients received only PCL reconstruction without combined severe associated posterolateral instability. From 1996 to 1998, there were 24 patients who had a quadriceps tendon autograft, and 30 patients with hamstring tendon autograft. Twenty-two of the quadriceps tendon group and 27 of the hamstring tendon autograft group with 2 more years of complete follow-up were included for final analyses. Clinical assessments consisted of Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle girth and strength, and radiographic evaluation. Results: On the Lysholm knee rating, 86% of patients showed good or excellent results in the quadriceps tendon group and so did 89% of patients in the hamstring tendon group. Fifty-nine percent of the quadriceps tendon group and 56% of the hamstring tendon group revealed a 3- to 5-mm ligament laxity. Two patients with quadriceps tendon grafts and 4 patients with hamstring tendon grafts revealed grade II laxity. The IKDC rating showed no significant difference between the 2 groups in terms of activity level, ligament laxity, and final rating. In the thigh girth side-to-side difference, 82% of the quadriceps tendon group and 78% of the hamstring tendon group had less than a 10-mm difference. Conclusions: Comparable satisfactory results between the 2 surgical groups were shown at a minimal 2 years follow-up. We suggested that both grafts could afford good ligament reconstruction likelihood and that they are reasonably acceptable graft choices for PCL reconstruction.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 6 (July-August), 2002: pp 603–612

Arthroscopic reconstruction of the posterior cruciate ligament with quadruple hamstring tendon graft: a double fixation method.

Surgical reconstruction is indicated for posterior cruciate ligament (PCL) reconstruction for a grade III or IV injury, combined ligament or meniscus injuries, and chronic symptomatic posterior instability. Considerable controversy continues over the choice of graft tissues. Hamstring tendon has been popular in recent years. The purpose of this study is to prospectively assess the outcomes of PCL reconstruction using quadruple hamstring tendon autograft with a double-fixation technique at minimal 2-year follow-up. Only patients who received PCL reconstruction without combined associated posterolateral injury reconstruction were included in the series. A hamstring tendon graft is composed of a quadruple-stranded semitendinosus tendon and gracilis tendon 10 cm in length. An arthroscopic technique using a two-incision method and a double-fixation technique were used. Clinical assessments were performed for 30 patients, of which 27 were available for final outcome analysis. Clinical review of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle assessment, and radiographic evaluation. On the Lysholm knee rating, 89% of the patients demonstrated good or excellent results in the final assessment. In the IKDC rating analyses, 56% of the patients revealed 3- to 5-mm ligament laxity. Four patients (15%) had grade II laxity. For the IKDC final rating, 26% were normal and 55% were nearly normal. Seventy-eight percent of the patients had less than a 10-mm difference in thigh girth between their reconstructed and opposite limbs. Arthroscopic PCL reconstruction with quadruple hamstring tendon autograft appears to produce acceptable results at a minimal 2-year follow-up. The four-stranded hamstring tendon graft is adequate in graft size and associated with minimal harvesting morbidity. The double-fixation method for the graft could provide a rigid fixation. We believe that this technique could afford good ligament function after reconstruction and could be a reasonably acceptable choice for PCL injury.