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Year : 2014  |  Volume : 14  |  Issue : 2  |  Page : 89-93

Clinical outcomes following anterior cruciate ligament reconstruction utilizing hamstring tendon autografts

Department of Orthopedics, Bahrain Defense Force Hospital, Ar-Rifaa, Bahrain

Date of Web Publication9-Oct-2014

Correspondence Address:
Naif Mohammed Alhamam
Department of Orthopedics, King Faisal University Hospital, Al-Ahsa, Kingdom of Saudi Arabia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-6308.142351

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Background: A case series demonstrating functional outcomes of 36 patients 2 years following anterior cruciate ligament (ACL) reconstruction utilizing hamstring autografts is presented here. We employed a quadruple bundle technique with cortical endobutton fixation. Materials and Methods: The methods of evaluation comprised of the 2000 International Knee Documentation Committee (IKDC) knee forms, clinical hamstring and quadriceps muscle strength testing in guidance with the Medical Research Council (MRC) grading, single leg triple hop assessment for distance, and the 'Aircast Rolimeter' arthrometer for objective joint laxity. Results: Mean IKDC score was 84.05 ± 14.37. A clinical final evaluation of normal or nearly normal was obtained by 97.2% (35/36) the participants. Passive motion deficit measured clinically using a goniometer was also found to be normal or nearly normal in 97.2% (35/36). One hundred percent of patients had normal or near normal grades for clinical manual knee ligament tests, 94.4% (34/36) patients had normal or near normal compartmental findings, and 100% of patients had normal or near normal harvest site findings. Hamstring muscle strength of the operated knee was clinically assessed to be 5/5 in 86.11% of candidates, while quadriceps muscle strength measured 5/5 in 100% of the subjects. The triple leg hop for distance demonstrated optimal performance with a limb symmetry index of 95.3 ± 13.3%. Arthrometric measurements revealed a mean side to side difference of + 0.70 ± 1.78 mm with Lachman's test and + 0.67 ± 1.43 mm with the anterior drawer test between the operated knee and the normal contralateral knee. Conclusion: We conclude that at 18 months following ACL reconstruction with hamstring auto grafts, our subject group displayed exceptionally satisfactory functional outcomes.

  Abstract in Arabic 

النتائج السريرية التالية لإعادة بناء الرباط الصليبي الأمامي في أوتار الركبة باستخدام طعم وتري ذاتي.
خلفية البحث : في هذا المقال عرضت النتائج الوظيفية لستة و ثلاثين من المرضى الذين خضعوا لإعادة بناء الرباط الصليبي الأمامي في أوتار الركبة باستخدام طعم ذاتي لوتر باطن الركبة ولمدة عامين. وقد استخدمت حزمة رباعية من التقنية لتثبيت القشرة الداخلية .
المواد والطرق: تألفت طرق التقييم من ألفيى حالة من وثائق الجمعية الدولية للركبة ((IKDC كما استخدم اختبار سريري لقوة العضلات رباعية الرؤوس استرشادا بمقاييس مجلس البحوث الطبية( MRC) كما استخدم قياس حركات المفصل لمعرفة مدى رخاوته.
النتائج : كانت نتائج الجمعية الدولية للركبة 84.5 -+ 14.37 . كما حصلت نسبة 97.2 ( 35/36) من المبحوثين على التقييم النهائي الطبيعي و شبه الطبيعي. و تم قياس قصور الحركة وضعفها باستخدام مقياس الزوايا فأظهرت نتائج التقييم الطبيعي و شبه الطبيعي نسبة 97.2% ( 35/36) وفي الاختبار اليدوي للرباط الصليبي الأمامي لأوتار الركبة أظهرت نسبة 100% من المرضى نتائج طبيعية أو شبه طبيعية ، و أظهرت نسبة (94.4%) من المرضى (34/36) نتائج طبيعية أو شبه طبيعية ، كما أظهرت نسبة 100% من المرضى نتائج طبيعية و شبه طبيعية . و كان التقييم السريري لقوة وتر باطن الركبة (5/5) في 86.11% من المبحوثين، في حين كان قياس قوة العضلة رباعية الرؤوس (5/5)في جميع من المبحوثين . أما في المقياس الثلاثي فقد أظهر مقياس حركات المفصل فرقا بلغ 1.78 ± 0.70 مع اختبار Lachman و ±1.43 0.67 مع اختبار لتشخيص تمزق الأربطة الداخلية للركبة التي خضعت للتدخل الجراحي مقارنة بالأخرى التي لم تخضع للجراح
الخلاصة : خلصت الدراسة الى ان اعادة بناء الرباط الصليبي الأمامي في أوتار الركبة باستخدام طعم وتري ذاتي يكفل اعادة خصائص مفصل الركبة بشكل مرضى.

Keywords: Anterior cruciate ligament reconstruction, endobutton, international knee documentation committee, quadruple bundle, triple leg hop

How to cite this article:
Al-Khalifa FK, Alhamam NM, Uddin FZ, Aljawder AA, Abubaris RK, Hameed R. Clinical outcomes following anterior cruciate ligament reconstruction utilizing hamstring tendon autografts . Saudi J Sports Med 2014;14:89-93

How to cite this URL:
Al-Khalifa FK, Alhamam NM, Uddin FZ, Aljawder AA, Abubaris RK, Hameed R. Clinical outcomes following anterior cruciate ligament reconstruction utilizing hamstring tendon autografts . Saudi J Sports Med [serial online] 2014 [cited 2023 Dec 10];14:89-93. Available from: https://www.sjosm.org/text.asp?2014/14/2/89/142351

  Introduction Top

Anterior cruciate ligament (ACL) is an important knee-stabilizing ligament frequently injured in athletes and trauma victims. In the United States there are an estimated 100,000-200,000 ruptures annually, with an incidence of over one in 3,500. [1],[2],[3]

The primary role of the ACL is to prevent anterolateral displacement of the tibia on the femur. Its secondary function is to prevent tibial rotation and to resist varus displacement at 0 degrees of flexion. [4]

ACL ruptures may occur with both high and low energy mechanisms. A low energy noncontact injury during an athletic activity, accounts for roughly 70% of ACL tears. [5],[6] Typically this involves athletes who suddenly decelerate, change directions, or pivot their knee. Video assessments of ACL tear biomechanics have found that the majority of injuries occur when an athlete moves their leg forcefully into a valgus position with the knee extended and the tibia rotated internally. [7],[8] Contact injuries occur due to a direct blow causing hyperextension or valgus stress to the knee. After the injury most patients experience recurrent episodes of pain, effusion, instability, and decreased function. [9] Though there is some speculation that surgical treatment increases the incidence of arthrosis [10] of the knee, the overall consensus is that ACL reconstruction allows earlier return to sporting activities, prevents the development of meniscal injury, and delays the onset of osteoarthritis. [11],[12]

At the time of ACL reconstruction, the surgeon aims to reestablish the biomechanical strength, stiffness, kinematics, and the physiometry which is provided by the native ACL. The most commonly used grafts are patellar tendon grafts, hamstring tendon grafts, and allografts. Patellar tendon grafts have the potential for bone to bone healing, thereby allowing earlier osteointegration compared to others. [13] It is stronger and stiffer than the normal ACL and provides greater stability. Systematic reviews have implicated that reconstruction with patellar autografts results in significant patient morbidity, particularly anterior knee pain. [14],[15],[16] Furthermore, there is evidence that they increase the long-term risk of osteoarthritis in the patient's knee. [17] Reconstruction with allografts reduces the total time of the procedure and decreases patient morbidity. Disadvantages include slower remodeling and integration of the graft, increased procedure cost, increased risk of bacterial infection, possible disease transmission, and immunological reactions. [18],[19],[20] Hamstring tendon grafts eliminate the morbidity associated with patellar tendon use. They are also stronger and stiffer when the quadruple strand technique is used. [21] The article by Hamner et al., demonstrates the superior load to failure of the quadruple bundle graft (2,422 N ± 538) when compared with that of the patellar tendon graft (1,784 N ± 580). [22] Chen et al., report level 5 evidence that ACL reconstruction using a quadrupled hamstring autograft has little morbidity, low reoperation rate, and optimal clinical results. [23] Systematic reviews have found initial donor site pain to resolve by 3 months and full hamstring function to return by 12 months. [15] Poorer healing and slower initial fixation are well-known associated problems. The endobutton has been found to address this particular issue. [15]

The availability and public acceptance of allografts limits the use of this option in our society. In our center, ACL reconstruction using patellar tendon autografts has been replaced since 2009 by quadruple bundle hamstring autografts utilizing endobutton fixation.

Our proposed study allows us to evaluate the subjective, objective, and functional outcome of our current ACL reconstruction method and thereby providing means for comparison. Such information is necessary to the continuous stride towards improving surgical outcome and patient care.


To assess the subjective, objective, and functional outcomes of ACL reconstructions utilizing quadruple strand technique and cortical endobutton fixation.

  Materials and methods Top

In 2011, we conducted a retrospective study to evaluate the outcomes of our preferred method of ACL reconstruction. All patients who underwent single-sided ACL reconstruction with a quadrupled hamstring autograft and endobutton fixation by the same surgeon were recruited into the study 2 years following their surgical intervention. Those with prior knee surgeries, concurrent pathology of the meniscus, and abnormal contralateral knee were excluded. Informed consent was obtained by all of the participants. All patients subsequently underwent the same accelerated postoperative rehabilitation program at our physiotherapy center.

With all our patients, a minimal graft diameter of 9 mm was ensured. Meniscal integrity was also judged intraoperatively. The tibial tunnel was drilled from the anteromedial aspect of the tibia entering the joint at the posterior aspect of the ACL footprint. The femoral tunnel was drilled in the medial aspect of the lateral femoral condyle transtibially. The graft was secured on the femoral side using a closed-loop endobutton (Smith and Nephew) and on the tibial end with two tibial staples at approximately 10 degrees of flexion.

Thirty-six patients were fit in the inclusion criteria. 5.6% (2/36) of the subjects were female. The average height of participants was 176.17 ± 6.95 cm (range: 158.7-186.0) and the average weight 87.24 ± 15.60 kg (range: 64.85-116.5). The mean age showed to be 25.8 ± 6.8 years (range: 16-39). BMI of participants ranged from 20.38 to 38.66 and averaged 28.10 ± 4.75 [Figure 1], [Figure 2], [Figure 3].
Figure 1: 2000 IKDC scores of subjects

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Figure 2: Limb Symmetry Index of subjects

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Figure 3: Mean side to side difference of Lachman's test and adt in subjects

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The subjects were evaluated using the '2000 International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form' and the '2000 IKDC Knee Examination Form'. A series of 10 questions assesses the subjective functionality of the patient's operated knee by concentrating on the following domains: Symptoms, sports activities, and function. A score of 0-100 is then calculated where 100 is interpreted to mean no limitations and the absence of symptoms. The subsequent form was used to evaluate our patients on the following parameters: Degree of effusion, passive motion deficit, manual knee laxity, compartment findings, harvest site pathology, one leg hop test, and an overall composite final evaluation. Furthermore, strength of the quadriceps and hamstring groups were tested clinically and scored according to the Medical Research Council (MRC) muscle strength grading. All clinical examinations were performed by the same physician and physiotherapist.

A single leg triple hop test for distance was employed to evaluate functional lower limb asymmetry by comparing the operated knee to the opposite one. [24],[25] This measure reflects the integrated effect of neuromuscular control, strength, stability of the reconstructed ligament, and confidence in the limb. As outlined by Noyel et al., [24] patients were instructed to stand on one leg, perform three consecutive hops as far as possible, and land on the same leg. A total of three attempts were allowed and the total distance was recorded. Performance of the reconstructed limb was measured as a percentage of the performance of the contralateral limb, termed as the "limb symmetry index" as described by Andrea et al. [26]

An objective evaluation of knee laxity using the 'Aircast Rolimeter' was performed. This simple exact operating device has been well-established in the literature to be a valid measure of anterior knee laxity. [27],[28] Lachman's test and the anterior drawer test (ADT) of the operated knee were conducted three consecutive times. The mean values were subsequently compared with corresponding results from the non-operated knee to obtain a side to side difference.

  Results Top

The scores of the '2000 IKDC Subjective Knee Evaluation Form' were divided into centiles. Sixteen patients fell in the 90-100 centile, eight patients in the 80-89 centile, four patients in the 70-79 centile, six patients in the 60-69 centile, one patient in the 50-59 centile, and one patient in the 40-49 centile. The mean IKDC score was 84.05 ± 14.37(range: 46-100).Results are shown in [Table 1].
Table 1: 2000 IKDC knee examination results of subjects

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Based on the '2000 IKDC Knee Examination Form' 88.89% (32/36) of patients had a normal grade of effusion. 11.11% (4/36) were graded as being near normal. 80.56% (29/36) of patients had a normal passive motion deficit, 16.67% (6/36) were grades as being near normal, and 2.86% (1/36) were found to be abnormal. In regards to manual knee laxity testing 88.89% of participants were graded as normal (32/36) and 11.11% (4/35) as near normal. 25.78% (10/36) of patients were found to have normal compartment findings; while 66.67% (24/36) and 5.71% (2/36) were found to have near normal and abnormal results, respectively. Normal harvest site pathology was found in 83.33% (30/36) of the participants, and 16.67% (6/36) scored as near normal. Coming to the single leg hop test, 69.44% (25/36) of patients were graded as having near normal functionality, 27.78% (10/36) as near normal, and 2.78% (1/36) as abnormal. The composite final evaluation showed that 69.44% (25/36) patients had an overall normal grading. 27.78% (10/36) received a near normal grading, and 2.78% (1/36) were graded as being abnormal.

Muscle strength on the operated side hamstring strength was graded as 5/5 in 86.11% (31/36) and 4/5 in 13.89% (5/36) of the subjects. 100% (35/35) of the test participants scored 5/5 on quadriceps testing on the operated knee. While, 100% (35/35) of patients received a score 5/5 on both quadriceps and hamstrings strength testing of the opposite knee.

The triple hop test for distance revealed an average limb symmetry index of 95.3 ± 13.3%. The values ranged from 61.5 to 136.7% with a median of 95.2%.

The knee laxities of the operated knee of our subjects were compared with that of their contralateral index knee using the Rolimeter. The mean side to side difference utilizing the Lachman's test was + 0.70 ± 1.78 mm. The mean difference in laxity in the anterior drawer test was + 0.67 ± 1.43 mm.

  Discussion Top

The mean patient reported outcome score was 84.05, with only two out of 36 patients reporting a score below 60. It was discovered that both these participants had demonstrated poor compliance with the rehabilitation program. We conclude this to be the main determinant of their unsatisfactory outcome. Nonetheless, the overall results are superior to those reported in the literature for semitendinosus autografts, [29] patellar tendon autografts, [28] and tibialis tendon allografts. [30] Clinical examination findings regarding effusion, passive motion deficit, and manual knee laxity were encouraging, with greater than 80% patients falling into the 'normal' subgroup and the vast majority of the remainder into the 'near normal' subgroup. The same two patients were found to have 'abnormal' compartment findings. All patients were found to have 'normal' or 'near normal' harvest site pathology. Regarding the hop test, only one patient was found to have an 'abnormal' score. All but one patient achieved an overall score of 'normal' or 'near normal'. Not a single patient was found to have 'severely abnormal' pathology in any of the measured parameters. The composite final evaluation revealed a normal or near normal score in 97.2% (35/36) of the subjects. Again, superior to other outcomes reported in the literature and at a shorter follow-up. [29],[30],[31] Leiter et al., [32] reports a 75% score of normal or near normal on the IKDC on a 12 year + follow-up of 68 patients reconstructed with a hamstring autograft.

Clinical muscle examination reveals marginal weakness of 4/5 in the hamstring muscles on the operated side in 86.11% of patients. This is the expected limitation in using hamstring autografts. This donor site weakness is an established consequence and is reported to resolve. [15],[29] Full quadriceps strength is evident in all subjects.

Objective knee laxity measurements revealed a side to side difference of just +0.7 and +0.67 mm on Lachman's and anterior drawer test, respectively. As a difference of greater than 3 mm is regarded as ACL deficiency, [27] these results demonstrate inherent stability.

We believe our study design to be comprehensive, allowing us to evaluate our subjects subjectively, objectively, and functionally. We regard our results to be highly satisfactory. One important variable we had not evaluated from the onset was the adherence and compliance to the postoperative rehabilitation program. This directly correlates to the overall outcome of the procedure. By taking this factor into consideration, clinicians will be better equipped to identify the factors behind any shortcomings.

  Conclusion Top

Patients undergoing primary ACL reconstruction at our hospital using the aforementioned technique and graft displayed highly favorable outcomes. The clinical relevance of this data is significant. It reaffirms the successful nature of this technique in a concise reproducible manner. A baseline has been developed from which various other reconstruction methods can be judged. These comparisons between various operative techniques are essential in the continuous strive to improve surgical outcome and patient care.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

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