In this study, we analyzed the clinical outcomes at two years following reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented with a symptomatic torn anterior cruciate ligament.

1. Arthroscopic Anterior Cruciate Ligament Reconstruction Using
Four-Strand Hamstring Graft – A Prospective Medium Term Study

2. Original Article
ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING FOURSTRAND HAMSTRING GRAFT – A PROSPECTIVE MEDIUM TERM STUDY+
KJ Reddy*, P Sunil Reddy#,Aashay L Kekatpure@ and Ajay Tiwari@
* Senior Consultant, # Consultant, @DNB Orthopaedics Resident, Department of Orthopaedics, Apollo Hospitals,
Jubilee Hills, Hyderabad 500 033, India.
Correpondence to: Dr K J Reddy, Senior Consultant, Department of Orthopaedics, Apollo Hospitals,
Jubilee Hills, Hyderabad 500 033, India.
Background: In this study, we analyzed the clinical outcomes at two years following reconstruction of the
anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented
with a symptomatic torn anterior cruciate ligament. Methods: Twenty four consecutive patients who had an
isolated, symptomatic anterior tibial subluxation associated with rupture of the anterior cruciate ligament were
treated with reconstruction of the anterior cruciate ligament with a four-strand autologous semitendinosusgracilis tendon graft. One surgeon performed all of the operations. Prior to surgery and at the follow-up
examination, physical findings and functional scores were recorded and knee radiographs were analyzed.
Following surgery, a six-month rehabilitation regimen was implemented. Results: Of the 41 patients operated
24 were available for follow-up. Twenty three of the patients had stable pain free knee negative Lachman and
pivot shift tests. The mean IKDC score improved from an average preoperative from 38.62 point to average at
final follow up 89.11 points at the time of follow-up (p < 0.01). One patient (5.5%) had a positive Lachmann’s
test at final follow up. One patient
had a traumatic rupture of the graft, occurring at a 16 months
postoperatively. Conclusions: Reconstruction of the anterior cruciate ligament with use of a four-strand
hamstring tendon autograft eliminated anterior tibial subluxation in 94.5% of patients who were examined at a
minimum of two years postoperatively. The functional knee scores were significantly increased at the time of
follow-up. Objective: A prospective study of 24 patients of Arthroscopic ACL reconstruction, all operated on by
a Single Surgeon followed up for 24 months.All the patients were operated between January and December
2005. Of the 41 patients operated, 24 were available for regular followup till 2 years. The study assessed the
Clinical outcome at various intervals during the study period.
Key words: Anterior cruciate ligament reconstruction, Hamstring tendon autograft.
INTRODUCTION
IN patients with symptomatic ACL deficient knees, ligament
reconstruction is the means of stabilizing and restoring high
level function of the knee joint. The ‘ideal’ graft for use in
ACL reconstruction is still a matter of debate. Both BPTB
graft and Hamstring graft have comparable results in terms
of stabilizing the knee and provide 90-95% good to excellent
results functionally as well as on clinical and KT-1000
instrumented testing.
Recent surge of interest in Quadrupled Hamstring
tendon graft is due partly to (i) considerable improvements
in soft tissue graft fixation techniques (especially the
endobutton and transcondylar fixation devices) that have
resulted in reliable fixation with pull out strengths averaging
1345 N vs 710 N for BPTB graft fixed with interference
screws, (ii) increased concerns with anterior knee pain and
problems with knee extensor mechanism with Patellar
tendon graft.
METHOD OF STUDY
All twenty four patients in the age group 18- 40 years
with symptomatic ACL rupture treated by Arthroscopic
ACL reconstruction with Four strand Hamstring graft, and
available for regular followup till 24 months were included
in the study.All patients falling within the inclusion criteria
were evaluated by a detailed history and clinical
examination.
Preoperative
assessment
included
+ Presented at IOACON
Apollo Medicine, Vol. 6, No. 1, March 2009
Ultimately the choice of graft in ACL reconstruction
depends on the Surgeons experience and preference. Tissue
availability, patient preference and activity level, prior
surgeries and presence of chronic patello femoral pain
influence the choice in some patients. In this study we
analyzed the clinical outcomes of Arthroscopic ACL
reconstruction with Four strand Hamstring graft (Quadrupled Semitendinosus and Gracilis) in symptomatic,post
traumatic, isolated ACL deficient knees at a two year follow
up (all patients with positive Lachmann and Pivot shift
tests).
16

3. Original Article
RESULTS
assessment of Duration of injury; Mechanism of injury;
Clinical examination of knee;
International Knee
Documentation committee 2000 (IKDC) Subjective Knee
Evaluation Score. IKDC Score is a reliable and
reproducible indicator of knee function and correlates well
with the KT-1000 Arthrometric testing. It is scored by
summing the responses to 18 factors assessing knee
function and activity and transforming the score to a scale
of 0-100. Arthroscopy was done on all patients to treat
associated meniscal injury and confirm the diagnosis,
followed by Quadriceps and Hamstring strengthening
exercises and ACL Reconstruction after 4-6 weeks.
The mode of injury in the patients was: vehicular
injuries - 50%; sports-46%; others-4%. Associated meniscal
injury was found in 60% of patients (Medical meniscus 40%; Lat. Meniscus-15%; both-5%). The preoperative
IKDC scores were: Mean Score-38.62%; Range-16.09 to
51.72. The mean score were: pre-operative 38.62; 3 months
65.67; 1 year 84.30; 2 years 89.11. Flexion dificit of 5-10
deg. in 2 patients (9%) was found at 1 yr follow up. No
extension deficit was detected in any patient.
Laxity. One patient (5.5%) had a significant positive
lachman test at final follow up. One patient had post
traumatic rupture of ACL graft at 16 months post op. 89%
patients had a stable, pain free, functional knee joint. No
patient had anterior knee pain at 3 months follow up.
Diameter of Graft Harvested in patients was: 8 mm-85%
and 9 mm-15%.
The surgical procedures are listed below:
1.
Positioning and graft harvesting (Fig.1) through a 2
cm incision.
2.
Whip suturing the graft to make it into a four-strand
graft.
3.
Arthroscopic preparation of femoral and tibial (Figs.
2 -4) graft fixation sites.
4.
Arthroscopic placement of tibial tunnel.
5.
Femoral tunnel placement and drilling using guide for
arthroscopic tunnel placement.
6.
Drilling for Endobutton .
7.
Graft passage (Fig. 5) through both tunnels.
8.
Femoral fixation using Endobutton (Fig. 6) and tibial
fixation using interference screw.
9.
Post operative AP and lateral radiographs are shown in
Fig.7.
Fig.1
Hamstring graft harvested with tendin stripper; The
photo shows the tendons (Semitendonosis & Gracilis)
attached to their tibial insertion at Pes Anserinus.
Post operative protocol
1.
Full weight bearing mobilisation on day 1.
2.
Graduated exercise programme progressing to level
III – IV at 12 weeks.
3.
Full ROM at 6 weeks.
4.
Return to unrestricted activity/sports after 5-6 months.
Post operative evaluation
(a) IKDC scores at 3 wks, 6 wks, 12 wks, 6 months, 12
months and 2 yrs
(b) Range of motion
(c) Quadriceps power and extension deficit
(d) Laxity
(e) Anterior knee pain.
Fig.2 Arthroscopic view of tibial guide wire.
17
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4. Original Article
Fig.3
Arthroscopic view femoral jig at the medial aspect of
the lateral femoral condyle.
Fig.4 Arthroscopic view of femoral tunnel.
Fig.5 Hamstring graft in place at the end of the surgery.
Problems with graft harvesting
Fig. 6
Difficulty in harvesting Hamstring graft was
encouxntered in 2 patients (8%), graft harvested from C/L
thigh in one patient, and superficial infection in one patient,
which responded well to early exploration, debridement and
antibiotics. No patient had deep or knee joint infection.
ENDOBUTTON: Ensures reliable and responsible
femoral anchorage of the graft.
DISCUSSION
Successful clinical outcomes following anterior
cruciate reconstruction with a hamstring graft have been
reported by many authors [1-14]. In our study, anterior
cruciate reconstruction with a four-strand hamstring graft
resulted in a successful clinical outcome in 94.5% of
patients who were available for follow-up. Marder, et al.
Apollo Medicine, Vol. 6, No. 1, March 2009
Fig.7
18
(a)
(b)
Post operative (a) anteroposterior and (b) lateral
radiographs.

5. Original Article
utilized a two-bundle semitendinosus construct and two
femoral Endobuttons in sixty-two patients and reported
improved anterior stability compared with that in patient
who had been treated with a single semitendinosus bundle
[5]. Hoffmann, et al. reported in the results sixty-five
patients of anterior cruciate reconstruction with a doubledsemitendinosus-and-Endo-button construct that was
augmented with an extra-articular lateral repair [15].
traumatic rupture of bone-patellar tendon bone grafts used
for anterior cruciate reconstruction has been reported to be
0% to 2% [16,21,22] where as those for Hamstring graft is
about 5%.
We did not observe any clinically relevant knee pain or
motion loss at the time of follow-up. The absence of such
morbid findings following anterior cruciate reconstruction
with a hamstring graft may make this method of
reconstruction more desirable for certain patients (i.e., those
with chronic patellofemoral pain or patellofemoral cartilage
disorder) over the BPTB graft.
Nebelung, et al. reviewed the results of twenty-nine
anterior cruciate reconstructions with a doubled autogenous
semitendinosus tendon and a femoral Endobutton [9]. They
graded 66% of the results as normal or nearly normal using
the criteria of the International Knee Documentation
Committee. In the present study, we analyzed the
effectiveness of a double-loop (four-strand) semitendinosus- gracilis graft in eliminating symptomatic anterior
tibial subluxation caused by a torn anterior cruciate
ligament. Anterior tibial subluxation was eliminated in
94.5% of the patients who were examined at a mean of 2
years postoperatively. The remaining 5.5% of the patients
had a positive lachmanns and pivot shift at the follow-up
examination. Bach et al. reported a reoperation rate of 15%
in a series of 103 patients evaluated two years after anterior
cruciate reconstruction with a patellar tendon autograft
[16].
CONCLUSION
We found that a four-strand semitendinosus-gracilis
autograft with a torn anterior cruciate ligament in 94.5% of
the patients who were available for follow-up. Significant
improvements in functional scores were noted. Four strand
hamstring graft is an effective treatment option for patients
with symptomatic ACL tears without any concerns
regarding knee extensor mechanisms or anterior knee pain.
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