Abstract:Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in orthopaedics, with more than 125,000 performed in the United States per year. There are several reconstruction graft choices that can be used to reconstruct the native anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used. Preparation of a hamstring autograft varies depending on patient characteristics and physician preference. The purpose of this Technical Note is to describ… Show more
“…H amstring tendon autografts have always stimulated surgeons' ingenuity and creativity with respect to anterior cruciate ligament (ACL) graft fixation and graft preparation techniques. 1 Early on, surgeons focused on developing strong and reliable graft fixation devices and techniques that would allow hamstring tendon autografts to be rigidly fixed to bone, thus allowing early motion and early weight bearing to be safely performed. The biomechanical study of Hamner et al 2 demonstrating that equally-tensioned doubled gracilis and semitendinosus hamstring tendon grafts were stronger and stiffer than the "gold standard" bone-patellar tendon-bone autograft was the foundation for establishing 4-strand hamstring tendon grafts as the standard method for preparing hamstring tendon ACL grafts (Fig 1).…”
Section: See Related Article On Page 2633mentioning
The concept of a five-strand hamstring tendon autograft for anterior cruciate ligament reconstruction is not new. The concept of a five-strand hamstring tendon autograft was largely ignored until recent studies showed higher failure and revision rates for hamstring ACL reconstructions performed with graft diameters less than 8 mm. In the majority of patients in the United Arab Emirates, four-strand hamstring tendon autografts result in a graft diameter between 6.5-7.5 mm. As a result, since 2006, I have completely abandoned using four-strand hamstring tendon autografts in favor of five-and six-stranded hamstring tendon autografts for ACL reconstructions. The key to performing five-or six-strand hamstring tendon autografts lies in the ability to triple the semitendinosus tendon and in the case of six-strand hamstring tendon grafts, the gracilis tendon. Although, five-and six-strand hamstring tendon autografts can increase the diameter of hamstring tendon ACL grafts, the question of whether these grafts will reduce failure and revision rates remains unanswered.
“…H amstring tendon autografts have always stimulated surgeons' ingenuity and creativity with respect to anterior cruciate ligament (ACL) graft fixation and graft preparation techniques. 1 Early on, surgeons focused on developing strong and reliable graft fixation devices and techniques that would allow hamstring tendon autografts to be rigidly fixed to bone, thus allowing early motion and early weight bearing to be safely performed. The biomechanical study of Hamner et al 2 demonstrating that equally-tensioned doubled gracilis and semitendinosus hamstring tendon grafts were stronger and stiffer than the "gold standard" bone-patellar tendon-bone autograft was the foundation for establishing 4-strand hamstring tendon grafts as the standard method for preparing hamstring tendon ACL grafts (Fig 1).…”
Section: See Related Article On Page 2633mentioning
The concept of a five-strand hamstring tendon autograft for anterior cruciate ligament reconstruction is not new. The concept of a five-strand hamstring tendon autograft was largely ignored until recent studies showed higher failure and revision rates for hamstring ACL reconstructions performed with graft diameters less than 8 mm. In the majority of patients in the United Arab Emirates, four-strand hamstring tendon autografts result in a graft diameter between 6.5-7.5 mm. As a result, since 2006, I have completely abandoned using four-strand hamstring tendon autografts in favor of five-and six-stranded hamstring tendon autografts for ACL reconstructions. The key to performing five-or six-strand hamstring tendon autografts lies in the ability to triple the semitendinosus tendon and in the case of six-strand hamstring tendon grafts, the gracilis tendon. Although, five-and six-strand hamstring tendon autografts can increase the diameter of hamstring tendon ACL grafts, the question of whether these grafts will reduce failure and revision rates remains unanswered.
“…Traditionally, hamstring tendons have been used as four strand grafts, either as doubled semitendinosous and gracilis tendons (Ferretti et al 2011 ) or as quadrupled semitendinosous tendon (Streich et al 2013 ) graft. Subsequently, semitendinosous tendon has been used in triplicate (Chambat et al 2013 ; Vinagre et al 2017 ; Zysk et al 2000 ). Tripled tendon is longer than quadrupled tendon, and is thicker than a doubled tendon.…”
Section: Introductionmentioning
confidence: 99%
“…Since suture fixation is an inferior form of fixation, the biomechanical strength of a three strand graft attached to a suspensory fixation device is equivocal (Snow et al 2012 ). Moreover, different methods of tripling the tendon graft has been described in literature (Krishna et al 2018 ; Lee 2013 ; Snow et al 2012 ; Vinagre et al 2017 ; Zysk et al 2000 ). Fig.…”
BackgroundTripling semitendinosus tendon for ACL graft preparation facilitates creation of longer and thicker grafts. Our objective was to evaluate the mechanical difference between tripled tendon grafts, prepared by three methods, by comparing with quadrupled tendon graft.MethodsBovine hind-foot hoof extensors were allocated to four groups. Group I had quadrupled graft construct. Tripled graft constructs were prepared by passing the tendon to the Endobutton CL loop and stitching the third strand to (i) the loop (in Group II) or (ii) to one strand(in Group III) or (iii)to loop and both tendon strands (in Group IV). The constructs were preloaded from 10 to 50 N at 0.1 Hz for 10 cycles, followed by 1000 cycles of sinusoidal loading between 50 and 250 N at a frequency of 0.5 Hz. The specimens were then subjected to load to failure test at the rate of 50 mm/min. Displacement with cyclic loading, load at failure and the mode of failure were noted.ResultsThe load at failure was 957 ± 23.30 N (Mean ± Standard Deviation) in Group I, 590.8 ± 24.40 N in Group II, 682.6 ± 59.28 N in Group III and 963.4 ± 21.72 N in Group IV. The displacement with cyclic loading was 1.13 ± 0.11 mm in Group I, 4.908 ± 0.55 mm in Group II, 1.822 ± 0.55 mm in Group III and 1. 126 ± .018 mm in Group IV. There was no significant difference between the Groups I and IV with respect to the load at failure and displacement (p > 0.05). The values were significantly different in Group II and Group III (p < 0.01), when compared to groups I and IV.ConclusionsTripled grafts have mechanical properties equivalent to quadrupled grafts only when the three strands are sutured together. Caution may be warranted when using suspensory fixation device with tripled tendons and the third strand must be securely attached to the loop of fixation device and to the other two strands.
“…Both Lavery et al 15 and Lee and Ganley 16 described techniques to create 5-strand hamstring grafts, but they did not biomechanically test their constructs or report clinical outcomes. Vinagre et al 17 described 7 different alternative hamstring autograft preparations to achieve minimum diameter requirements and acknowledged the need to biomechanically compare them. Fritsch et al 18 created an algorithm with several techniques to construct 4-, 5-, 6-, ;or 8strand grafts (as needed) to achieve grafts of larger diameter, and they proposed performing comparative studies to validate its outcomes.…”
To biomechanically compare alternative graft constructs for all-inside anterior cruciate ligament (ACL) reconstruction in the event that the semitendinosus harvested is too narrow or too short to make a graft larger than 8 mm. Methods: Bovine extensor tendons were used to make 6 different 9-mm-diameter grafts: traditional 4-strand, anastomosis 4-strand, 6-strand, 3-strand, button-fixation 4-strand, and loopand-tack 4-strand grafts. The grafts were then subjected to cyclic biomechanical testing followed by failure loading. Force at 3 and 5 mm of displacement and ultimate force were recorded for all grafts. Results: Compared with the traditional 4-strand graft, the only graft that showed significant biomechanical differences during the cyclic phase of testing was the button-fixation 4-strand graft, which was characterized by lower force at 3 mm of displacement (74 ± 34 N vs 122 ± 13 N, P =. 004) and 5 mm of displacement (122 ± 35 N vs 172 ± 3 N, P = .006). During failure loading, ultimate force was significantly lower for both the 6-strand graft (491 ± 186 N, P = .041) and button-fixation 4-strand graft (326 ± 27 N, P < .001) than for the traditional 4-strand graft (778 ± 176 N). All other grafts were equivalent for the parameters tested. Conclusions: The anastomosis 4-strand, 3-strand, and loop-and-tack 4-strand grafts do not biomechanically differ in cyclic loading and ultimate force from traditional 4-strand grafts. This study supports the use of anastomosis 4-strand, 3-strand, or loop-and-tack 4-strand grafts in the event that a traditional all-inside 4-strand graft cannot be prepared from a harvested semitendinosus tendon in ACL reconstruction. Clinical Relevance: This study tests and describes alternatives to the traditional 4-strand semitendinosus autograft for all-inside ACL reconstruction in the event that the harvested tendon is not adequate. Interest has peaked recently regarding the size of 4-strand hamstring autografts in all-inside anterior cruciate ligament (ACL) reconstruction and its effect on clinical outcome and graft
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