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

Krishna, Lingaraj; Tan, Xiaoxue; Wong, Keng Lin; Toh, Shi Jie

doi:10.1177/2325967118760815

Cited by 19 publications

(60 citation statements)

References 19 publications

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“…Despite significantly larger grafts in the five-strand group (9.06 vs. 8.13 mm), they failed to demonstrate a significant difference in clinical outcomes between groups. 16 Conversely, these data demonstrate a significantly smaller increase than a recently published randomized clinical trial that reported an increase of 1.4 mm (AE0.3 mm) in graft size in a five-strand configuration. 15 Moreover, these data also differ from a separate retrospective study in which the authors compared groups of patients who underwent ALCR using either a five-or four-strand configuration.…”

Section: Discussioncontrasting

confidence: 63%

“…In fact, despite the increase in graft size in a five-strand configuration in previous studies, none of the authors could demonstrate a statistically significant difference in clinical outcomes and/or re-rupture rates between groups. 4,15,16 When comparing hamstring graft size without controlling for different configurations, Conte et al demonstrated that a graft diameter of 8 mm was associated with a 6.8 times higher relative risk of future graft failure. 5 This systematic review also supports previous observational studies demonstrating that decreased hamstring autograft size is associated with early revision.…”

Section: Discussionmentioning

confidence: 99%

“…5 This systematic review also supports previous observational studies demonstrating that decreased hamstring autograft size is associated with early revision. 10,16 For example, Magnussen et al demonstrated that the highest risk of graft revision was with ACLR diameters 8 mm in patients younger than 20 years. 10 Given these findings, we wished to determine the proportion of grafts that achieved a threshold greater than 8 mm in diameter.…”

Section: Discussionmentioning

confidence: 99%

“…In the study by Krishna et al, 16 an average increase in graft diameter of 0.5 mm would be needed to achieve a graft diameter greater than 8 mm for an average four-strand configuration. We hypothesize that there would be at least a 0.5-mm increase in graft diameter when a five-strand configuration was used compared with a four-strand configuration.…”

Section: A Priori Power Analysismentioning

confidence: 99%

“…3,20 Therefore, a reliable means of increasing hamstring tendon autograft size intraoperatively without using allograft tendons can potentially improve the outcomes of hamstring tendon ACLR. 1,4,5,7,9,13,16,18,[22][23][24][25] Several previous studies have described a five-strand hamstring autograft configuration, leveraging the extra length of the semitendinosus. 4,[16][17][18]25 In a recent retrospective study, the clinical outcomes of the five-strand hamstring autograft were at least comparable with those of four-strand hamstring autograft when it was used to augment an intraoperative graft diameter of <8 mm.…”

mentioning

confidence: 99%

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

et al. 2019

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Intraoperative 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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Section: Discussioncontrasting

confidence: 63%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: A Priori Power Analysismentioning

confidence: 99%

mentioning

confidence: 99%

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

et al. 2019

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

Malesa,

Tramś,

Kuliński

et al. 2024

Knee surg. sports traumatol. arthrosc.

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PurposeThis 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.MethodsA 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.ResultsThe 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).ConclusionThe 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 EvidenceNetwork meta‐analysis of level I–III studies.

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Hamstring graft diameter above 7 mm has a lower risk of failure following anterior cruciate ligament reconstruction

Alomar

Nasser

Kumar

et al. 2021

Knee Surg Sports Traumatol Arthrosc

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Purpose Multi-stranded hamstring-tendon autografts have been widely used for anterior cruciate ligament reconstruction (ACLR) surgeries. Recently, smaller diameter hamstring autografts have been linked with the risk of failure or graft rupture. However, there is limited evidence concerning the optimal diameter of the hamstring autografts for ACLR. The current systematic review and meta-analysis analysed the association of ACLR failure with the diameter of hamstring autografts. Methods A systematic search of three major scientiic databases (Pubmed, EMBASE, and Cochrane library) was conducted to identify studies that presented ACLR failure-related outcomes with diferent diameters of hamstring autografts. The pooled data from the included studies were analysed to investigate the association between ACLR failure and the cut-of diameters of 6, 7, 8, and 9 mm. Subgroup analyses based on the level of evidence and follow-up duration were also performed at each cut-of diameter. Results Of the 2282 studies screened, 16 reported failure rates with hamstring autografts of diferent diameters, 15 of which were included in the meta-analysis. A graft diameter ≥ 7 mm was associated with signiicantly lower ACLR failure rates than a graft diameter < 7 mm (p = 0.005), based on pooled data of 19,799 cases. Age < 20 years and higher physical activity were associated with signiicantly higher ACLR failure rates. ConclusionThe current systematic review suggests that the hamstring graft diameter for ACLR should be more than 7 mm considering the signiicantly higher failure rates with graft diameters less than 7 mm.

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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

Cited by 19 publications

References 19 publications

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

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

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

Hamstring graft diameter above 7 mm has a lower risk of failure following anterior cruciate ligament reconstruction

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