The effectiveness of quadrupled semitendinosus graft technique in anterior cruciate ligament reconstruction: A network meta-analysis assessing various graft preparation techniques.

PURPOSE: This study aims to perform a network meta-analysis of hamstring graft preparation techniques to enhance anterior cruciate ligament (ACL) reconstruction guidelines and inform clinical decision-making in patients with primary ACL rupture. METHODS: A review of the literature, from 1 January 1990, to 31 August 2023, was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, focusing on the clinical outcomes of various hamstring graft preparation techniques. Forty-six studies (over 4800 knees) were analysed. Eight graft compositions: doubled hamstring (ST/G)-1978 grafts, doubled hamstring with augmentation (ST/G+A)-586 grafts, tripled semitendinosus (3ST)-124 grafts, quadrupled semitendinosus (4ST)-1273 grafts, five-strand tripled semitendinosus + doubled gracilis (3ST/2GR-839 grafts, six-strand tripled semitendinosus + tripled gracilis (3ST/3GR)-335 grafts, seven-strand quadrupled semitendinosus + tripled gracilis (4ST/3GR)-11 grafts and ≥eight strands-24 grafts were compared, considering graft sizes, laxity, muscle strength, range-of-motion, patient-reported outcome measures (PROMs), return to sport (RTS) and adverse events. RESULTS: The 4ST grafts fared better than the ST/G grafts in the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Q and RTS (mean difference [MD], -1.69; p = 0.0159; MD, -1.55; p = 0.0325; MD, -1.93; p = 0.001; odds ratio: 3.13; p < 0.0001). The IKDC differed significantly between the 4ST and ST/G+A groups (MD, 1.88; p = 0.046). The ST/G+A resulted in the lowest knee laxity, surpassing the ST/G, 3ST and 4ST. The ST/G had the smallest diameter (ST/G vs. ST/G+A: MD, 1.26; 95% confidence interval [CI]: 0.67-1.86, p < 0.0001). Reduced failure rates were noted with the 3ST/2GR (3ST/2GR vs. ST/G: MD, 6.93; p = 0.009) and 3ST/3GR (3ST/3GR vs. ST/G: MD, 53.64; p = 0.006). CONCLUSION: The ideal hamstring graft for ACLR should be individualized. A 4ST graft is likely to yield good PROMs. For high stability and rapid RTS, adding augmentation to the graft is advisable. The ST/G is the thinnest graft possible. LEVEL OF EVIDENCE: Network meta-analysis of level I-III studies.

Functional Outcome of Single-Bundle Arthroscopic Anterior Cruciate Ligament Reconstruction using Peroneus Longus Graft and Hamstring Graft: An Open-Label, Randomized, Comparative Study.

Background This study investigates the functional outcomes of single-bundle arthroscopic anterior cruciate ligament (ACL) reconstruction, comparing the use of two distinct graft sources: peroneus longus (PL) graft and hamstring graft. The choice of graft material in ACL reconstruction is crucial for optimal postoperative results, and this study aims to contribute valuable insights into the comparative efficacy of these two graft types. Method This open-label randomized comparative study involved a carefully selected cohort of patients undergoing single-bundle arthroscopic ACL reconstruction. Participants were randomly assigned to either the PL graft group or the hamstring graft group. Surgical procedures were conducted using standardized techniques, and postoperative rehabilitation protocols were closely monitored. Functional outcomes, including range of motion, stability, and patient-reported measures, were assessed at predefined intervals to ensure comprehensive data collection. Results The study underscores significant demographic and clinical factors in ACL reconstruction outcomes. Participants were predominantly aged 17-30 years (58.33%) with a mean age of 29.27 years and exhibited a male predominance (80.56%). Common complaints included knee pain and instability, primarily due to falls from bikes (55.56%) or sports-related trauma (44.44%). Notably, PL grafts demonstrated advantages over hamstring grafts, with longer mean length (10.11 mm vs. 8.77 mm, p=0.0001) and shorter operation times. Visual analog scale (VAS), International Knee Documentation Committee (IKDC), and Tegner Lysholm scores show no significant differences between grafts over the period of time. There is no notable foot eversion weakness or significant donor site morbidity after the PL graft harvest. Hamstring graft cases exhibit a higher incidence of altered sensation and muscle atrophy, suggesting the potential benefits of PL grafts for improved surgical outcomes. Conclusions Graft comparisons favored PL grafts due to longer length, and functional outcome assessments between the two graft types. However, foot and ankle strength assessments revealed fluctuations in strength recovery with PL grafts, highlighting the need for tailored rehabilitation. Thigh circumference variations suggested potential muscle atrophy in the hamstring graft group, along with reported paresthesia in the ipsilateral proximal leg. In conclusion, PL grafts offer potential advantages for ACL surgery, but ongoing monitoring and specialized rehabilitation are crucial.

Scapulothoracic tenodesis using hamstring tendon graft for treatment of problematic scapula winging: A new surgical technique.

Introduction: Winging of the scapula occurs due to dysfunction of its stabilising muscles, most commonly serratus anterior and/or trapezius, for example in facioscapulohumeral muscular dystrophy. Resultant loss of scapular control and abnormal kinematics can decrease shoulder function due to glenohumeral joint instability, loss of range of motion and pain. Previously described treatment for cases resistant to physiotherapy includes scapulothoracic arthrodesis which involves risk of non-union and metalwork failure, as well as reduced respiratory function due to immobilisation of a segment of the adjacent chest wall. Technique: We present a novel surgical approach to the management of problematic scapular winging by using hamstring graft to achieve a scapulothoracic tenodesis. Discussion: We believe this technique provides an adequately stable scapula for improved shoulder movement and function, a sufficiently mobile chest wall for improved lung function and avoidance of complications specifically associated with arthrodesis.

Enlightenment on Knee Flexors Strength Loss in Cases of Posterior Knee Pain After Anterior Cruciate Ligament Reconstruction.

CONTEXT: The persistence and the recurrence of posterior medial knee pain (PKP) after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon graft are often overlooked during rehabilitation. DESIGN: Cross-sectional observational study. METHODS: The study aimed (1) to evaluate the prevalence of these types of PKP before 4 months post-ACLR, (2) to measure their consequences on the knee flexors strength, and (3) to evaluate the role of the type of ACLR. From a cohort of patients operated on with hamstring tendon procedures, the persistent and the recurrent PKP were sought at 4 months post-ACLR. The evolution of isokinetic muscle strength recovery in PKP subjects was compared with those of nonpainful subjects. The functional deficit was measured at 6/7 months post-ACLR by a hop test. RESULTS: Three hundred seventeen subjects (25.8 [6.0] y) were included. At 4 months post-ACLR, 2 populations were identified based on the recurrent onset of PKP (PKP+, n = 40) or the absence of knee pain (PKP-, n = 277). The prevalence of PKP was 8.3%. At the fourth month post-ACLR, the PKP+ group had a higher flexor strength deficit compared with the PKP- group (limb symmetry index at 60°/s: 67.2% [12.4%] vs 84.3% [12.6%]; P < .05). At 6/7 months, the loss of strength persisted (limb symmetry index at 60°/s: 82.3% [13.4%] vs 87.7% [12.8%]; P < .05). The hop test deficit was comparable, and no difference was shown according to the type of graft. CONCLUSIONS: Persistent and recurrent PKP during the rehabilitation period were not uncommon and were associated with a worsening of flexors strength loss on the ACLR side.

Influence of female sex and double-quadruple semitendinosus-gracilis graft on the incidence of postoperative symptomatic cyclops lesions after ACL reconstruction.

PURPOSE: Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR. METHODS: This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model. RESULTS: In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014). CONCLUSION: This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions. LEVEL OF EVIDENCE: Level III.

Novel technique of predicting the dimensions of 5-stranded hamstring grafts for anterior cruciate ligament reconstruction: A descriptive study.

Background: Prediction of hamstring tendon autografts is essential when planning a ligament reconstruction surgery. This is especially important in cases of multiple ligament reconstruction surgeries. This study was designed to predict the dimensions of 5-stranded hamstring grafts from anthropometric parameters in patients undergoing anterior cruciate ligament (ACL) reconstruction surgery. Methods: 172 patients undergoing ACL reconstruction with hamstring autografts were included in the study. Preoperative parameters included age, gender, height, weight, body mass index (BMI), thigh length, thigh circumference, and tibia length; intraoperative parameters included semitendinosus (ST) and gracilis (G) length and diameter, final 5-stranded graft length and diameter. Pre-operative data was correlated with intra-operative data using tests of significance. Results: Height, tibia and thigh length were greater in males (p < 0.05) whereas BMI was greater in females (p < 0.05). G and ST length alongwith 5-stranded graft length and diameter were significantly greater in males (p < 0.05). The graft dimensions could be correlated with the pre-operative anthropometric parameters using specific equations. This was applicable to the lengths and diameters of ST, G and 5-stranded grafts. We also noted that an increase in age was associated with a reduction in graft dimensions except for the diameter of G graft in females and length of 5-stranded grafts in males. Conclusion: 5-stranded hamstring graft dimensions can be reliably predicted using anthropometric parameters and this eases surgical planning.

Hamstring graft size for anterior cruciate ligament repair in a sample of Iraqi men.

The goal of the current investigation was to measure the size of the anterior cruciate ligament (ACL) graft following hamstring (gracilis and semitendinosus) tendon autograft procedures in a relatively large sample size of Iraqi men. In this study, the quadruple hamstring tendon (semitendinosus and gracilis) was measured in a sample of Iraqi adult males. The study enrolled 300 Iraqi men who underwent anterior cruciate ligament repair at Diwaniyah Teaching Hospital and Alforat Alawast Private Hospital between January 2020 and December 2021. The repair procedure was based on the utilization of the quadruple (gracilis and semitendinosus) hamstring tendon. The primary outcome measure was the size of the tendon, determined using a sizing tube calibrated to 0.5 mm. Out of the sample, 80% of patients had a graft diameter of 7.5 mm, while 15% had a graft diameter of 8 mm, and 5% had a diameter of 7 mm. Body mass index was a poor predictor of graft size, whereas patient height was an excellent predictor of graft diameter. The graft diameter in most Iraqi subjects with anterior cruciate ligament injuries needs to be five bands or even six bands; otherwise, other graft sources like bone-patellar-bone or peroneus longus tendon grafts should be considered. The graft diameter may be reliably anticipated based on the patient's height.

Can We Predict ACL Hamstring Graft Sizes in the Asian Male? A Clinical Relationship Study of Anthropometric Features and 4 Strand Hamstring Graft Sizes

Introduction: This study was undertaken to investigate if such anthropometric measurements (i.e., height, weight and body mass index) can be used to predict graft diameters in 4 strand semitendinosus and gracilis hamstring autografts. Methods: The study sample consisted of 89 consecutive male patients who underwent ACL reconstruction using quadrupled semitendinosus and gracilis autografts. Intraoperative measurements of the fashioned quadrupled hamstring graft were performed using sizing tubes calibrated t

Comparison of Clinical Results According to Amount of Preserved Remnant in Arthroscopic ACL Reconstruction using Quadrupled Hamstring Graft / 대한정형외과학회잡지

PURPOSE: To analyze the clinical results in an ACL reconstruction according to the amount of the tibial remnant of the ACL using a hamstring graft and looped sutures. MATERIALS AND METHODS: Sixteen patients who were followed up for at least 12 months after the ACL reconstruction with four strands of a hamstring tendon using a looped suture technique were enrolled in this study. The average follow-up was 35.1 months. At the last follow-up period, the patients were evaluated using the International Knee Documentation Committee (IKDC) scale and the HSS score, Lachman test, ant. drawer test, KT-1000, one-leg hoop test and proprioceptive function test (motion and position sense). They were then divided two groups according to whether they had more or less than 30% of the ACL remaining. The final results of the two groups were statistically compared. RESULTS: Average HSS score improved from 65.8 (preoperative) to 95.2 (last follow-up). No significant differences in functional outcome and mechanical stability were found except for proprioception. Regarding the threshold of the detection of the passive motion test at 30 degrees (p=0.030) and the reproduction of the passive positioning test at 15 degrees (p=0.032) and 30 degrees (p=0.024), the more remnant preserved group (>30%) showed better results than the less preserved group. CONCLUSION: Preserving the tibial remnant will preserve function of the mechanoreceptors and be helpful to the recovery of the function and healing of a graft after surgery.