A 5-Strand Hamstring Autograft Achieves Outcomes Comparable to Those of a 4-Strand Hamstring Autograft With a Graft Diameter of 8 mm or More in Anterior Cruciate Ligament Reconstruction

Background: Quadrupled (4-strand) hamstring tendon autografts are commonly used in anterior cruciate ligament (ACL) reconstruction, but there is significant variability in their diameter. The 5-strand hamstring autograft has been used as a means of increasing the graft diameter in patients with undersized hamstring grafts. Purpose: To report the outcomes of primary ACL reconstruction using 5-strand hamstring autografts in patients in whom the 4-strand configuration produced a graft diameter of <8 mm and to compare these outcomes with those of ACL reconstruction using 4-strand semitendinosus-gracilis autografts with a graft diameter of ≥8 mm. Study Design: Cohort study; Level of evidence, 2. Methods: The primary study group comprised 25 patients who underwent ACL reconstruction using a 5-strand hamstring autograft. The comparison group comprised 20 patients who underwent ACL reconstruction using a 4-strand hamstring autograft with a graft diameter of ≥8 mm. Interference screw fixation was used at the tibial and femoral ends for both groups of patients. Subjective questionnaires, including the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score, and the Physical Component Summary and Mental Component Summary of the Short Form–36 (SF-36), were administered preoperatively as well as at 1- and 2-year follow-up visits. Results: There were no significant differences in the patient demographics and preoperative scores between the 2 groups. The mean graft diameter was 9.06 ± 0.60 mm in the 5-strand group and 8.13 ± 0.32 mm in the 4-strand group ( P < .05). There was no statistically significant difference between groups on postoperative Lysholm, KOOS Pain, KOOS Symptoms, KOOS Activities of Daily Living, KOOS Sports, KOOS Quality of Life, and SF-36 Physical Component Summary scores. Conclusion: In primary ACL reconstruction, the 5-strand hamstring autograft achieves clinical outcomes that are comparable to those of the 4-strand hamstring autograft with a graft diameter of ≥8 mm. The 5-strand graft technique is therefore a useful means of increasing the graft diameter when faced with an undersized hamstring graft.

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Vancomycin presoaking of hamstring grafts removes the risk of infection in primary anterior cruciate ligament reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00184 ◽

2018 ◽

Vol 6 (12_suppl5) ◽

pp. 2325967118S0018

Author(s):

Francisco Figueroa ◽

David Figueroa ◽

Rafael Calvo ◽

Alex Vaisman ◽

Mario López ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Septic Arthritis ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Hamstring Autograft ◽

Exact Test ◽

Previous Period ◽

Anterior Cruciate ◽

Primary Acl Reconstruction ◽

Hamstring Grafts

Background: Several strategies have been studied to decrease the rate of infection after hamstring autograft anterior cruciate ligament (ACL) reconstruction. Our group started presoaking grafts with Vancomycin in November 2015 to decrease this risk. Purpose: The objective of the study is to compare the success of this protocol against the immediate previous period in which we did not use the protocol. Study design: Retrospective cohort. Level III. Methods: Consecutive periods were studied: April 2013-October 2015 (pre Vancomycin protocol) and November 2015- May 2018 (Vancomycin protocol). All patients that underwent a hamstring autograft primary ACL reconstruction during the periods studied were included. The final outcome was the presence of postoperative septic arthritis in both groups. Diagnosis of septic arthritis was made using the clinical picture plus cytological analysis of a joint aspiration (cell count > 50.000/uL + > 90% neutrophils) Statistical analysis was made using the Fisher’s exact test. Significance was set in p < 0.05. Results: 490 patients were included in the study, 230 in the pre Vancomycin protocol an 260 in the Vancomycin protocol. 4 postoperative septic arthritis were noted in the pre Vancomycin protocol (1.7%) while no septic arthritis was noted in the post Vancomycin protocol patients during the period studied. (p < 0.05) The 4 postoperative infections were presented at an average 21.7 days (range 16-25). Staphylococcus epidermidis was isolated in 2 of the cases, and in the other 2 no organism was isolated. Conclusion: Vancomycin presoaking of hamstring autografts in primary ACL reconstruction eliminated the risk of postoperative septic arthritis during the studied period compared to the immediate previous period, where no Vancomycin presoaking was used.

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Five-Strand Hamstring Autograft in Primary Anterior Cruciate Ligament Reconstruction

The Journal of Knee Surgery ◽

10.1055/s-0038-1641175 ◽

2018 ◽

Vol 32 (04) ◽

pp. 366-371

Author(s):

Lingaraj Krishna ◽

Xin Yang Tan ◽

Acksen Thangaraja ◽

Francis Wong

Keyword(s):

Acl Reconstruction ◽

Screw Fixation ◽

Cruciate Ligament ◽

Interference Screw ◽

Hamstring Graft ◽

Hamstring Autograft ◽

Interference Screw Fixation ◽

Anterior Cruciate ◽

Graft Diameter ◽

Primary Acl Reconstruction

AbstractThe purpose of this study was to describe our surgical technique of using five-strand hamstring autograft with interference screw fixation in primary anterior cruciate ligament (ACL) reconstruction and to report the early postoperative outcomes of this technique. Patients who underwent primary ACL reconstruction using five-strand hamstring autografts with interference screw fixation between December 2014 and June 2016 were included in this study. The five-strand configuration was used in these patients because the four-strand configuration produced a graft diameter of less than 8 mm. Subjective questionnaires, including the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm Score, were administered preoperatively, as well as at 1- and 2-year follow-ups. Paired t-test was used to compare the pre- and postoperative outcome scores. The study group comprised 25 patients. There were no intraoperative complications. The mean follow-up period was 17.8 months (12–24). There were 19 males and 6 females. The median age was 24 years (16–41), and median body mass index was 23.9 (18.5–30.2). The median diameter of the five-strand graft was 9 mm (8–10 mm), with a mean of 9.06 ± 0.60 mm. This was associated with a median graft length of 90 mm (80–100 mm). The postoperative Lysholm, KOOS symptoms, KOOS Pain, KOOS daily function, KOOS sports function, KOOS quality of life, and Short Form-36 Physical Component Summary scores improved significantly compared with the preoperative scores. The use of the five-strand hamstring graft with interference screw fixation in primary ACL reconstruction is associated with significant improvements in patient-reported outcomes in the early postoperative period. The five-strand graft technique is a useful means of increasing graft diameter when faced with an undersized hamstring graft.

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Hamstring autograft size importance in anterior cruciate ligament repair surgery

EFORT Open Reviews ◽

10.1302/2058-5241.3.170038 ◽

2018 ◽

Vol 3 (3) ◽

pp. 93-97 ◽

Cited By ~ 7

Author(s):

Francisco Figueroa ◽

David Figueroa ◽

João Espregueira-Mendes

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Hamstring Autograft ◽

Ligament Repair ◽

Graft Size ◽

Acl Surgery ◽

Anterior Cruciate Ligament Repair ◽

Anterior Cruciate ◽

Graft Diameter

Graft size in hamstring autograft anterior cruciate ligament (ACL) surgery is an important factor directly related to failure. Most of the evidence in the field suggests that the size of the graft in hamstring autograft ACL reconstruction matters when the surgeon is trying to avoid failures. The exact graft diameter needed to avoid failures is not absolutely clear and could depend on other factors, but newer studies suggest than even increases of 0.5 mm up to a graft size of 10 mm are beneficial for the patient. There is still no evidence to recommend the use of grafts > 10 mm. Several methods – e.g. folding the graft in more strands – that are simple and reproducible have been published lately to address the problem of having an insufficient graft size when performing an ACL reconstruction. Due to the evidence presented, we think it is necessary for the surgeon to have them in his or her arsenal before performing an ACL reconstruction. There are obviously other factors that should be considered, especially age. Therefore, a larger graft size should not be taken as the only goal in ACL reconstruction. Cite this article: EFORT Open Rev 2018;3:93-97. DOI: 10.1302/2058-5241.3.170038

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Intraoperative Conversion to Five-Strand Hamstring Autograft Configuration Significantly Increases Anterior Cruciate Ligament Graft Diameter Independent of Patient Characteristics

The Journal of Knee Surgery ◽

10.1055/s-0039-3400955 ◽

2019 ◽

Cited By ~ 1

Author(s):

Brian E. Walczak ◽

Scott J. Hetzel ◽

Craig Chike Akoh ◽

Geoffrey S. Baer

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Patient Characteristics ◽

Hamstring Tendon ◽

Hamstring Autograft ◽

Significant Difference ◽

Anterior Cruciate ◽

Intraoperative Conversion ◽

Graft Diameter

AbstractIntraoperative conversion of a four-strand hamstring autograft to a five-strand configuration during an anterior cruciate ligament (ACL) reconstruction has been reported. However, the expected change in graft size and the dependence on patient characteristics are currently not well described. The purpose of this study was to determine the effective change in hamstring graft diameter and reliance on patient characteristics when intraoperatively converting a four-strand hamstring autograft into a five-strand configuration during an ACL reconstruction. A prospective, paired cohort study design was used to measure individual hamstring autograft diameter intraoperatively using traditional four-strand configuration followed by a five-strand configuration. All hamstring tendons included were long enough to consider a five-strand configuration. Five-strand hamstring autograft increased graft diameter in all patients. Hamstring tendon graft diameter increased by an average of 0.99 mm (95% confidence interval [CI]: 0.84–1.11) in the five-strand configuration compared with the traditional four-strand configuration (mean: 7.8 mm). There was no significant difference in the average increase in graft diameter between males (1.04 mm) and females (0.92 mm) (p = 0.323). Eighty-three percent (95% CI: 57.8–95.6) of average graft diameters ≤ 8 mm in the four-strand configuration achieved an average graft diameter of >8 mm in the five-strand configuration, and 70% (95% CI: 35.4– 91.9) of four-strand configuration average diameters < 8 mm achieved an average graft diameter > 8.0 mm in the five-strand configuration. Five-strand hamstring autograft reliably increased intraoperative hamstring tendon autograft diameter, with an average of 1 mm, compared with traditional four-strand configuration. This increase in diameter is independent of sex and remained significant when controlling for age, laterality, body mass index, and semitendinosus length.

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Presoaking of Hamstring Autografts in Vancomycin Decreases the Occurrence of Infection Following Primary Anterior Cruciate Ligament Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119871038 ◽

2019 ◽

Vol 7 (9) ◽

pp. 232596711987103 ◽

Cited By ~ 3

Author(s):

David Figueroa ◽

Francisco Figueroa ◽

Rafael Calvo ◽

Mario Lopez ◽

Ignacio Goñi

Keyword(s):

Anterior Cruciate Ligament ◽

Septic Arthritis ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Fisher Exact Test ◽

Hamstring Autograft ◽

Level Of Evidence ◽

Exact Test ◽

Anterior Cruciate ◽

Primary Acl Reconstruction

Background: Postoperative septic arthritis is an uncommon but potentially devastating complication after anterior cruciate ligament (ACL) reconstruction. Our group started presoaking grafts with vancomycin to decrease this risk. Purpose: To compare the rate of septic arthritis in primary hamstring autograft ACL reconstruction with and without vancomycin-presoaked grafts. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive periods were studied, inclusive of April 2013 through October 2015 (pre-vancomycin protocol) and November 2015 through May 2018 (vancomycin protocol). A total of 490 patients were included in the study: 230 in the pre-vancomycin protocol and 260 in the vancomycin protocol. All patients who underwent a primary hamstring autograft ACL reconstruction by 2 senior surgeons during the periods studied were included. The final outcome studied was occurrence of highly probable postoperative septic arthritis in both groups. Diagnosis of probable septic arthritis was made by clinical diagnosis as well as cytological analysis of joint aspiration (cell count >50,000/μL and >90% neutrophils). Statistical analysis was performed with the Fisher exact test. Significance was set at P < .05. Results: Four cases of probable postoperative septic arthritis were noted in the pre-vancomycin protocol (1.7%; 2 cases per surgeon), while no cases of septic arthritis were noted in the vancomycin protocol during the study period ( P < .05). Diagnosis was made at a mean 21.7 days (range, 16-25 days). Staphylococcus epidermidis was isolated in 2 cases, and in the other 2 cases, no organism was isolated. Conclusion: Presoaking of hamstring autografts in vancomycin for primary ACL reconstruction prevented the occurrence of postoperative septic arthritis during the study period as compared with no soaking of the grafts.

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Performance of the PROMIS in Patients After Anterior Cruciate Ligament Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118774509 ◽

2018 ◽

Vol 6 (5) ◽

pp. 232596711877450 ◽

Cited By ~ 16

Author(s):

Elizabeth J. Scott ◽

Robert Westermann ◽

Nathalie A. Glass ◽

Carolyn Hettrich ◽

Brian R. Wolf ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Physical Function ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Sf 36 ◽

Significant Difference ◽

Patient Reported ◽

Floor Effects ◽

Anterior Cruciate ◽

Pro Instruments

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) is designed to advance patient-reported outcome (PRO) instruments by utilizing question banks for major health domains. Purpose: To compare the responsiveness and construct validity of the PROMIS physical function computer adaptive test (PF CAT) with current PRO instruments for patients before and up to 2 years after anterior cruciate ligament (ACL) reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Initially, 157 patients completed the PROMIS PF CAT, Short Form–36 Health Survey (SF-36 physical function [PF] and general health [GH]), Marx Activity Rating Scale (MARS), Knee injury and Osteoarthritis Outcome Score (KOOS activities of daily living [ADL], sport, and quality of life [QOL]), and EuroQol–5 dimensions questionnaire (EQ-5D) at 6 weeks, 6 months, and 2 years after ACL reconstruction. Correlations between instruments, ceiling and floor effects, effect sizes (Cohen d), and standardized response means to describe responsiveness were evaluated. Subgroup analyses compared participants with and without additional arthroscopic procedures using linear mixed models. Results: At baseline, 6 weeks, and 6 months, the PROMIS PF CAT showed excellent or excellent-good correlations with the SF-36 PF ( r = 0.75-0.80, P < .01), KOOS-ADL ( r = 0.63-0.70, P < .01), and KOOS-sport ( r = 0.32-0.69, P < .01); excellent-good correlation with the EQ-5D ( r = 0.60-0.71, P < .01); and good correlation with the KOOS-QOL ( r = 0.52-0.58, P < .01). As expected, there were poor correlations with the MARS ( r = 0.00-0.24, P < .01) and SF-36 GH ( r = 0.16-0.34, P < .01 ). At 2 years, the PROMIS PF CAT showed good to excellent correlations with all PRO instruments ( r = 0.42-0.72, P < .01), including the MARS ( r = 0.42, P < .01), indicating frequent return to preinjury function. The PROMIS PF CAT had the fewest ceiling or floor effects of all instruments tested, and patients answered, on average, 4 questions. There was no significant difference in baseline physical function scores between subgroups; at follow-up, all groups showed improvements in scores that were not statistically different. Conclusion: The PROMIS PF CAT is a valid tool to assess outcomes after ACL reconstruction up to 2 years after surgery, demonstrating the highest responsiveness to change with the fewest ceiling and floor effects and a low time burden among all instruments tested. The PROMIS PF CAT is a beneficial alternative for assessing physical function in adults before and after ACL reconstruction.

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Factors Associated With Psychological Readiness to Return to Sports With Cutting, Pivoting, and Jump-Landings After Primary ACL Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120964484 ◽

2020 ◽

Vol 8 (11) ◽

pp. 232596712096448

Author(s):

Junya Aizawa ◽

Kenji Hirohata ◽

Shunsuke Ohji ◽

Takehiro Ohmi ◽

Hideyuki Koga ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Regression Analysis ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Return To Play ◽

Return To Sports ◽

Factors Associated ◽

Anterior Cruciate ◽

Primary Acl Reconstruction ◽

Jump Landings

Background: High psychological readiness is an important element for returning to sports after anterior cruciate ligament (ACL) reconstruction. Identifying factors that contribute to psychological readiness is essential for planning interventions to return to play. No studies have used multivariate analysis to clarify factors associated with psychological readiness to return to specific sports. Hypothesis: To identify factors that contribute to an athlete’s psychological readiness to return after ACL reconstruction to sports that require cutting, pivoting, and jump-landings. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Study participants were athletes who before injury had participated in sports with limited contact that required cutting, pivoting, and jump-landings (basketball, soccer, futsal, volleyball, badminton, tennis, and frisbee) and hoped to return to the same sport after reconstruction. Psychological readiness was measured using the Anterior Cruciate Ligament–Return to Sport After Injury Scale (ACL-RSI) in athletes more than 6 months after primary ACL reconstruction. To clarify factors associated with the ACL-RSI, univariate regression analysis and multivariate regression analysis were performed using the following independent variables: age, sex, body mass index, time from injury to reconstruction, time from reconstruction to testing, meniscal surgery, modified Tegner activity scale before injury, kinesiophobia, limb symmetry index of knee strength, limb symmetry indices of single-leg hop (SLH) distances, and subjective running ability. Results: Higher subjective running ability, a lower kinesiophobia score, and greater limb symmetry in the lateral SLH were positively associated with psychological readiness. Conclusion: The psychological readiness of athletes aiming to return after ACL reconstruction to limited-contact sports that require cutting, pivoting, and jump-landings was affected by subjective running ability, kinesiophobia, and asymmetry of lateral SLH distance. This information may be useful in planning appropriate interventions and thereby increasing the likelihood of an athlete’s returning to such sports.

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Incidence and Risk Factors of Subsequent Meniscal Surgery After Successful Anterior Cruciate Ligament Reconstruction: A Retrospective Study With a Minimum 2-Year Follow-up

The American Journal of Sports Medicine ◽

10.1177/0363546520967670 ◽

2020 ◽

Vol 48 (14) ◽

pp. 3525-3533

Author(s):

Yuka Kimura ◽

Eiji Sasaki ◽

Yuji Yamamoto ◽

Shizuka Sasaki ◽

Eiichi Tsuda ◽

...

Keyword(s):

Risk Factors ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Anterior Laxity ◽

Meniscal Surgery ◽

Anterior Cruciate ◽

Femoral Tunnel Drilling ◽

Primary Acl Reconstruction

Background: One of the goals of anterior cruciate ligament (ACL) reconstruction is a meniscal protective effect on the knee. Despite the advancement of ACL reconstruction techniques, subsequent meniscal tears after ACL reconstruction remain a problem, and the risk factors for recurring lesions are still unclear. Purpose: To investigate the incidence of subsequent meniscal surgery after primary ACL reconstruction without revision ACL surgery and to determine the risk factors associated with this reoperation. Study Design: Case series; Level of evidence, 4. Methods: Overall, 518 patients who underwent primary ACL reconstruction between 2004 and 2012 at one instution participated in this study. Data on body mass index, graft type and femoral tunnel-drilling technique of ACL reconstruction, and location and type of meniscal injury and its treatment at ACL reconstruction were collected from medical records. Clinical outcomes were investigated, including side-to-side difference of anterior laxity, pivot-shift grade, and subsequent meniscal surgery without ACL insufficiency (at minimum 2-year follow-up). Results: The prevalence of tears to the medial meniscus (MM) at the primary ACL reconstruction was 43.6% (226/518), 140 of which were repaired; on the contrary, tears of the lateral meniscus (LM) had a prevalence of 55.8% (289/518), 42 of which were repaired. At a mean 30.3 months (range, 8-124 months) after ACL reconstruction, 20 patients (3.9%; 14 MM tears, 3 LM tears, 3 MM + LM tears) required meniscal surgery without ACL reinjury or recurrence of instability. Of these, 14 MMs and 3 LMs had been repaired at primary ACL reconstruction. The failure rates of repaired MM and LM were 10.0% (14/140) and 7.1% (3/42), respectively. The failure rate of MM repair using the all-inside technique (6/36) was significantly higher compared with no treatment, inside-out repair, or partial resection ( P = .045). In multiple regression analysis, the presence of MM injury at the time of ACL reconstruction (odds ratio [OR], 7.81; P = .003), the side-to-side difference of postoperative anterior tibial translation (OR, 1.91; P = .032), and follow-up period after ACL reconstruction (OR, 1.02; P = .003) were risk factors of subsequent meniscal surgery after ACL reconstruction. Conclusion: Incidence of subsequent meniscal surgery after successful ACL reconstruction was <5%. Presence of MM tear at the time of ACL reconsturuction, small amount of increased anterior laxity, and long-term period after ACL reconstruction were predictive of subsequent meniscal surgery.

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Influence of graft diameter on patient reported outcomes after hamstring autograft anterior cruciate ligament reconstruction

Orthopedic Reviews ◽

10.4081/or.2019.8178 ◽

2019 ◽

Cited By ~ 2

Author(s):

Robert A. Duerr ◽

Kirsten D. Garvey ◽

Jakob Ackermann ◽

Elizabeth G. Matzkin

Keyword(s):

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Hamstring Autograft ◽

Cruciate Ligament Reconstruction ◽

Point Increase ◽

Patient Reported ◽

Anterior Cruciate ◽

Graft Diameter

Several studies have identified graft diameter as a risk factor for failure following anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate the effect of graft diameter on patient reported outcome measures (PROMS) following ACLR. We performed a retrospective review of prospectively collected data using a global surgical registry. 153 of 287 patients (53.3%) had complete data for each timepoint. Effect of graft diameter, graft type, femoral tunnel drilling technique, patient age, sex, and body mass index were evaluated. At 1-year post-operatively, a 1-mm increase in graft diameter was found to correlate with a 5.7-point increase in the Knee Injury and Osteoarthritis Outcome Score (KOOS) activity of daily living score (p = 0.01), a 10.3-point increase in the sport score (p=0.003), and a 9.8-point increase in the quality of life score (p=0.013). At 2-years post-operatively, a 1-mm increase in graft size was found to be marginally correlated with KOOS symptoms and sport scores. Patients undergoing hamstring autograft ACLR, increasing graft diameter can result in improved PROMS, specifically improved KOOS subscale scores at 1 and 2-years post-operative.

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