Article

Hamstring Pain and Muscle Strains Following Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Trial Comparing Hamstring Graft Harvest Techniques

Authors:
  • Perth Orthopaedic and Sports Medicine Centre, Perth ,Western Australia
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Abstract

There is limited information in the literature regarding hamstring pain and muscle strains in patients following anterior cruciate ligament (ACL) reconstruction using hamstring autograft. We sought to investigate whether dividing hamstring tendons distal to the musculotendinous junction rather than forcefully stripping tendons away from the muscle belly during graft harvest resulted in a lower incidence of hamstring pain, muscle strains, and leg flexion strength deficit following commencement of sport-specific training postoperatively. Patients were randomized to either the "Cut" or "Push" groups of hamstring tendon harvesting. All other operative techniques were uniform. A total of 34 (cut = 20, push = 14) patients had a mean follow-up of 30 months, and assessments were conducted by a blinded single practitioner. A customized hamstring strain questionnaire and visual analogue pain score provided information for the study's primary focus: evaluation of postoperative hamstring pain and muscle strains. Leg flexion strength was also measured and a full knee assessment was conducted. The Cincinnati sports activity rating scale (SARS) was used to account for varying degrees of sporting participation and intensity since reconstruction. The "Cut" group's mean visual analogue score was 10.05 mm, significantly lower than the "Push" group (24.66 mm, p = 0.0398). The Cut group also recorded a significant reduction in the incidence of hamstring strains following ACL reconstruction (5/20 patients 25%) compared with the Push group (7/14 patients 50%, p = 0.045). There was no difference in leg flexion strength between the groups. Of the patients who reported hamstring strains, there was no significant difference in the mean Cincinnati SARS between the groups, nor any difference in overall knee function. The incidence of hamstring pain and muscle strains was significantly reduced in patients receiving the "cut" technique of harvesting hamstring tendons in ACL reconstruction surgery, a difference that was not attributable to a lower level of sporting activity.

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... Moreover, in the present study a greater total volume of work was completed by the BFR groups, which may have influ- enced pain responses due to greater time under BFR. Regarding the BFR groups only, muscle pain and strains that are observed following ACLR surgery (D'Alessandro, Wake, & Annear, 2013) may contribute to the higher pain scores observed in the ACLR-BFR group compared to the non-injured BFR group, particularly if the ACLR-BFR group were present with some degree of muscle pain prior to exercise. ...
Article
Objectives: To compare the acute perceptual and blood pressure responses to: 1) light load blood flow restriction resistance exercise (BFR-RE) in non-injured individuals and anterior cruciate ligament reconstruction (ACLR) patients; and 2) light load BFR-RE and heavy load RE (HL-RE) in ACLR patients. Design: Between-subjects, partially-randomised. Methods: This study comprised 3 groups: non-injured BFR-RE (NI-BFR); ACLR patients BFR-RE (ACLR-BFR); ACLR patients HL-RE (ACLR-HL). NI-BFR and ACLR-BFR performed 4 sets (30, 15, 15, 15 reps, total = 75 reps, 30s inter-set rest) of unilateral leg press exercise at 30% 1RM with continuous BFR at 80% limb occlusive pressure. ACLR-HL performed 3 × 10 reps (Total = 30 reps, 30s inter-set rest) of unilateral leg press exercise at 70% 1RM. Perceived exertion (RPE), muscle pain, knee pain and pre- and 5-min post-exercise blood pressure were measured. Results: RPE was higher in ACLR-BFR compared to NI-BFR (p < 0.05). Muscle pain was higher in NI-BFR and ACLR-BFR compared to ACLR-HL (p < 0.05). Knee pain was lower in ACLR-BFR compared to ACLR-HL (p < 0.01). There were no differences in blood pressure. Conclusion: These responses to BFR exercise may not limit application and favourably influence knee pain throughout ACLR rehabilitation training programmes. These findings can help inform practitioners' decisions to utilise this tool.
... 57 58 Hamstring tendon harvest is also associated with local irritation, knee flexion weakness, hamstring strains and saphenous nerve injury. [59][60][61][62] While allograft use eliminates donor-site morbidity, potential problems include delayed incorporation, immunogenicity, and the potential for disease transmission, 63-65 as well as potentially increased costs. 66 Despite the relevance of donor site morbidity to the autograft/ allograft debate, complication reporting was inconsistent in the included studies. ...
Article
Importance Graft choice in anterior cruciate ligament (ACL) reconstruction is controversial. Recent evidence questions the equivalence of non-irradiated allografts to autografts in primary reconstruction. Aim To compare the clinical outcomes of primary ACL reconstruction using autografts and allografts. Evidence review A computerised search of the Pubmed/Medline, Cochrane Central Register of Controlled Trials, and SCOPUS databases was performed. We included comparative studies with level of evidence I to III, minimum 2 year follow-up, a minimum of 20 patients in each treatment arm, and selected outcome measures. Non-irradiated, non-chemically treated allografts and irradiated or chemically treated allografts were compared with autografts. The Cochrane Collaboration tool was used for quality appraisal. Findings Twenty-two studies were included for the systematic review. These included 1148 autografts, 939 non-irradiated, non-chemically treated allografts, and 308 irradiated or chemically treated allografts. The failure rates for both allograft groups were inferior to that of autograft, with the OR for failure favouring autografts versus non-irradiated, non-chemically treated allografts (OR 0.51, 95% CI 0.30 to 0.88), and irradiated or chemically treated allografts (OR 0.12, 95% CI 0.06 to 0.21). Other outcome measures, including the Lachman test, pivot shift, instrumented laxity testing, and IKDC scores demonstrated no statistically significant differences for autograft and non-irradiated, non-chemically treated allograft reconstructions. Irradiated and chemically treated allograft reconstructions were inferior to autograft reconstructions in almost every examined outcome measure. Conclusions and relevance In this level III systematic review, autograft reconstructions have a lower failure rate than both non-irradiated and irradiated allografts, particularly for younger patients. Other clinical outcome measures for autografts and non-irradiated allografts are not significantly different. Based on our results, it appears that irradiated and chemically-treated allografts have clearly inferior results, and surgeons should exercise caution when recommending ACL reconstruction with these allografts. Level of evidence III.
... The superior border of the pes anserinus was then incised to visualise the ST and GR tendons. The tendons were left secured to their distal attachment points and an open-ended tendon harvester (Linvatec, Largo FL) was used to release the tendons proximally from their muscular attachment points using a cut rather than a push technique[24]to a length of 22 cm in females and 24 cm in males. Then a quadrupled graft was formed by folding both tendons and wound together. ...
Article
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Background The muscle-tendon properties of the semitendinosus (ST) and gracilis (GR) are substantially altered following tendon harvest for the purpose of anterior cruciate ligament reconstruction (ACLR). This study adopted a musculoskeletal modelling approach to determine how the changes to the ST and GR muscle-tendon properties alter their contribution to medial compartment contact loading within the tibiofemoral joint in post ACLR patients, and the extent to which other muscles compensate under the same external loading conditions during walking, running and sidestep cutting. Materials and methods Motion capture and electromyography (EMG) data from 16 lower extremity muscles were acquired during walking, running and cutting in 25 participants that had undergone an ACLR using a quadruple (ST+GR) hamstring auto-graft. An EMG-driven musculoskeletal model was used to estimate the medial compartment contact loads during the stance phase of each gait task. An adjusted model was then created by altering muscle-tendon properties for the ST and GR to reflect their reported changes following ACLR. Parameters for the other muscles in the model were calibrated to match the experimental joint moments. Results The medial compartment contact loads for the standard and adjusted models were similar. The combined contributions of ST and GR to medial compartment contact load in the adjusted model were reduced by 26%, 17% and 17% during walking, running and cutting, respectively. These deficits were balanced by increases in the contribution made by the semimembranosus muscle of 33% and 22% during running and cutting, respectively. Conclusion Alterations to the ST and GR muscle-tendon properties in ACLR patients resulted in reduced contribution to medial compartment contact loads during gait tasks, for which the semimembranosus muscle can compensate.
... Journal of Sport Rehabilitation © 2016 Human Kinetics, Inc. risk for hamstring strain injury after returning to sports. 18,19 Several randomized controlled trials have found little or no differences, function or revision rates after ACLR was performed with the most frequently used autologous grafts (patellar tendon or hamstring tendons grafts). ...
Article
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Context- The muscular function restoration related to the type of physical rehabilitation followed after anterior cruciate ligament reconstruction (ACLR) using autologous hamstring tendon graft in terms of strength and cross sectional area (CSA) remain controversial. Objective- To analyze the CSA and force output of quadriceps and hamstring muscles in subjects following either an Objective Criteria-Based rehabilitation (OCBR) algorithm or the usual care (UCR) for ACL rehabilitation in Spain, before and one year after undergoing an ACLR. Design- Longitudinal clinical double blinded randomized controlled trial. Setting- Sports-medicine research center. Patients- 40 recreational athletes, 30 male, 10 female (24 ± 6.9 y, 176.55 ± 6,6 cm, 73.58 ± 12.3 kg). Intervention- Both groups conducted differentiated rehabilitation procedures after ACLR. Those belonging to OCBR group were guided in their recovery according to the current evidence-based principles. UCR group followed the national conventional approach for ACL rehabilitation. Main Outcome Measures- Concentric isokinetic knee joint flexor-extension torque assessments at 180º/s and Magnetic Resonance Imaging (MRI) evaluations were performed before and 12 months after ACLR. Anatomical muscle CSA (mm2) was assessed, in Quadriceps , Biceps femoris, Semitendinous, Semimembranosus and Gracilis muscles at 50 and 70% femur length. Results- Reduced muscle CSA was observed in both treatment groups for Semitendinosus and Gracilis one year after ACLR. At one year follow up, subjects allocated to the OCBR, demonstrated greater knee flexor and extensor peak torque values in their reconstructed limbs in comparison to patients treated by UCR. Conclusions- Objective atrophy of Semitendinosus and Gracilis muscles related to surgical ACLR was found to persist in both rehabilitation groups. However, OCBR after ACLR lead to substantial gains on maximal knee flexor strength and ensured more symmetrical anterior-posterior laxity levels at the knee joint.
... En France en 2013, 41 937 reconstructions du ligament croisé antérieur (LCA) ont été réalisées d'une durée moyenne de séjour hospitalier de 3,15 jours (http://www.atih.sante.fr/ statistiques-par-ghm-0). De nouvelles techniques chirurgicales diminuent la morbidité peropératoire [1,2] . L'anesthésie multimodale a pour vocation de limiter les effets délétères des morphiniques et d'améliorer la récupération postopératoire [3,4]. ...
Article
Résumé Introduction La faisabilité de la reconstruction du ligament croisé antérieur (LCA) en ambulatoire en France a été démontrée, essentiellement avec des techniques aux tendons ischio-jambiers (IJ). Le but de cette étude était d’analyser la reconstruction du LCA en ambulatoire selon le type de greffe, IJ (groupe 1) ou ligament patellaire (LP) (groupe 2). L’hypothèse était que cette prise en charge est compatible avec tout type de greffe. Matériel et méthode Une étude monocentrique rétrospective a été menée, les critères d’inclusion étaient les reconstructions primaires du LCA à partir du LP ou des IJ avec ou sans ténodèse latérale et l’âge supérieur à 16 ans. Ont été exclus les gestes osseux ou ligamentaires associés et les reconstructions itératives. Le critère principal d’évaluation était les complications pendant les 45 premiers jours postopératoires. Les critères secondaires d’évaluation étaient l’échelle visuelle analogique les trois premiers jours, la satisfaction à j3 et les scores cliniques IKDC et Lysholm au 45e jour. Résultats Cent quatre patients (104 genoux) ont été analysés dont 77 greffes (74 %) à partir des IJ et 27 (26 %) à partir du LP. Deux patients du groupe 1 (2,6 %) ont passé la nuit postopératoire dans l’établissement, deux autres ont été réhospitalisés. Dans le groupe 2, il n’y a eu aucune hospitalisation. Il n’y a eu aucune reprise chirurgicale pendant les 45 premiers jours postopératoires. Aucune différence significative n’a été mise en évidence entre les deux groupes pour les critères postopératoires étudiés. Discussion La reconstruction du LCA en ambulatoire est compatible quel que soit le type de greffe. La réussite de ce type de prise en charge dépend principalement du cheminement clinique des patients et du protocole d’anesthésie. Niveau de preuve Niveau IV, étude rétrospective.
... Additional complications of ACL reconstruction that have been reported in case series and retrospective literature include wound dehiscence, septic arthritis, [11][12][13][14][15] deep vein thrombosis, 16,17 and pulmonary embolism. 18 Reported adverse events may also include meniscal and chondral pathology, graft reruptures requiring revision surgery, graft failures, contralateral ruptures, graft hypertrophy/cyclops lesions/arthrofibrosis, 19-21 kneeling pain, 22 hamstring strain/rupture, 23 infections, 24,25 and nerve injury. 26,27 Csintalan et al 28 reported the risk factors and incidence of nonrevision reoperations for meniscal and cartilage problems, hardware removal, and arthrofibrosis, based on information collected in an ACL reconstruction registry over a 6-year period. ...
... Reconstruction of an unstable sternoclavicular joint using a tendon graft in a figure-of-eight fashion through drill-holes in the manubrium and medial end of the clavicle is biomechanically superior to other reconstruction techniques 26 and has been suggested as the preferred technique for sternoclavicular joint stabilization in patients with chronic instability requiring intervention 1,12 . Use of the ipsilateral sternocleidomastoid tendon obviates the need for second-site surgery with its related complications 27,28 , and avoids the local complications reported with synthetic augmentation techniques 29 . The aim of the present study was to evaluate the clinical outcomes of our patients who underwent sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft for chronic debilitating anterior instability of the sternoclavicular joint. ...
Article
Anterior instability of the sternoclavicular joint is uncommon and usually follows a benign course, although symptomatic patients may require surgical intervention. The optimal treatment for symptomatic instability of the sternoclavicular joint remains unclear. The aim of this study was to evaluate the clinical outcome after reconstruction of the sternoclavicular joint with use of a sternocleidomastoid tendon graft to treat chronic debilitating anterior instability of the sternoclavicular joint. Thirty-two patients underwent surgical reconstruction of the sternoclavicular joint for chronic debilitating anterior instability using the tendon of the sternal head of the ipsilateral sternocleidomastoid muscle and were followed for a mean of forty-four months. The etiology of instability was posttraumatic in fourteen patients, generalized hyperlaxity in seven patients, and degenerative instability in eleven patients. Outcome measures included the Oxford instability shoulder score, subjective shoulder value, pain rating, and postoperative grading of sternoclavicular joint stability. Clinical scores and pain rating were similar for the three groups before surgery and improved significantly in all of the groups to the same extent after the surgery. At the time of the latest follow-up, eleven of fourteen patients in the posttraumatic group, six of seven patients in the generalized hyperlaxity group, and eight of eleven patients in the degenerative group reported the sternoclavicular joint as stable with no functional limitation. Two patients reported that the joint remained unstable. No other complications occurred. Sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft is safe and offers reliable pain relief and functional improvement for patients with chronic debilitating anterior instability of the sternoclavicular joint. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
PurposeThis study aimed to evaluate the differences in clinical outcome and donor site morbidity between the Peroneus Longus Tendon (PLT) and Hamstring Tendon (HT) in single-bundle Posterior Cruciate Ligament (PCL) reconstruction.Methods Patients with an isolated PCL injury underwent single-bundle PCL reconstruction using consecutive sampling. Patients were allocated into two groups (PLT and HT) and prospectively observed. The tendon graft diameter was measured intraoperatively. Functional scores (IKDC, Lysholm, and modified Cincinnati scores) were recorded preoperatively and 2 years postoperatively. The thigh circumference and functional score according to the Foot and Ankle Disability Index (FADI) and American Orthopedic Foot and Ankle Society (AOFAS) were recorded to evaluate the morbidities in the ankle.ResultsFifty-five patients (hamstring n = 27, peroneus n = 28) met the inclusion criteria. The diameter of the PLT graft (8.2 ± 0.6 mm) was comparable to that of the HT graft (8.3 ± 0.5 mm). Both groups had excellent postoperative knee functional outcome scores. The mean AOFAS and FADI scores were excellent, with no difference in thigh circumference between the groups.ConclusionPLT is a good choice as a graft in PCL reconstruction at the 2-year follow-up, with minimal donor site morbidity.Level of evidenceII.
Article
Background Previous injury is a strong risk factor for recurrent lower limb injury in athletic populations, yet the association between previous injury and a subsequent injury different in nature or location is rarely considered. Objective To systematically review data on the risk of sustaining a subsequent lower limb injury different in nature or location following a previous injury. Methods Eight medical databases were searched. Studies were eligible if they reported lower limb injury occurrence following any injury of a different anatomical site and/or of a different nature, assessed injury risk, contained athletic human participants and were written in English. Two reviewers independently applied the eligibility criteria and performed the risk of bias assessment. Meta-analysis was conducted using a random effects model. Results Twelve studies satisfied the eligibility criteria. Previous history of an ACL injury was associated with an increased risk of subsequent hamstring injury (three studies, RR=2.25, 95% CI 1.34 to 3.76), but a history of chronic groin injury was not associated with subsequent hamstring injury (three studies, RR=1.14, 95% CI 0.29 to 4.51). Previous lower limb muscular injury was associated with an increased risk of sustaining a lower limb muscular injury at a different site. A history of concussion and a variety of joint injuries were associated with an increased subsequent lower limb injury risk. Conclusions The fact that previous injury of any type may increase the risk for a range of lower limb subsequent injuries must be considered in the development of future tertiary prevention programmes. Systematic review registration number CRD42016039904 (PROSPERO).
Chapter
Multiple questions about the morbidity of semitendinosus and gracilis tendon harvest have arisen due to their popularity as grafts for numerous reconstructive procedures. The goal of this chapter is to review what is known about the morbidity of hamstring harvest and factors that affect this morbidity. Evidence is very limited with regard to the relationship between hamstring harvest and subsequent hamstring injury. While the studies demonstrate that having a previous ACL reconstruction puts one at risk for hamstring injury, the relationship appears independent of graft type. Loss of hamstring strength following harvest for ACL reconstruction is a major concern. Knee flexion strength loss following hamstring harvest is generally between 5 and 15 %, with the greatest deficits noted at greater flexion angles. There is currently little evidence demonstrating improved outcomes with gracilis preservation or contralateral hamstring harvest. There does seem to be a correlation between tendon regeneration and the resultant strength and diameter of the muscle, although the functional consequences of a failure of the tendons to regenerate are poorly defined. More work is necessary to completely understand potential adverse effects of hamstring harvest.
Article
Background: The hamstring tendon graft used in anterior cruciate ligament (ACL) reconstruction has been shown to lead to changes to the semitendinosus and gracilis musculature. Hypothesis: We hypothesized that (1) loss of donor muscle size would significantly correlate with knee muscle strength deficits, (2) loss of donor muscle size would be greater for muscles that do not experience tendon regeneration, and (3) morphological adaptations would also be evident in nondonor knee muscles. Study design: Cross-sectional study; Level of evidence, 3. Methods: Twenty participants (14 men and 6 women, mean age 29 ± 7 years, mean body mass 82 ± 15 kg) who had undergone an ACL reconstruction with a hamstring tendon graft at least 2 years previously underwent bilateral magnetic resonance imaging and subsequent strength testing. Muscle and tendon volumes, peak cross-sectional areas (CSAs), and lengths were determined for 12 muscles and 6 functional muscle groups of the surgical and contralateral limbs. Peak isokinetic concentric strength was measured in knee flexion/extension and internal/external tibial rotation. Results: Only 35% of the patients showed regeneration of both the semitendinosus and gracilis tendons. The regenerated tendons were longer with larger volume and CSA compared with the contralateral side. Deficits in semitendinosus and gracilis muscle size were greater for muscles in which tendons did not regenerate. In addition, combined hamstring muscles (semitendinosus, semimembranosus, and biceps femoris) and combined medial knee muscles (semitendinosus, semimembranosus, gracilis, vastus medialis, medial gastrocnemius, and sartorius) on the surgical side were reduced in volume by 12% and 10%, respectively. A 7% larger volume was observed in the surgical limb for the biceps femoris muscle and corresponded with a lower internal/external tibial rotation strength ratio. The difference in volume, peak CSA, and length of the semitendinosus and gracilis correlated significantly with the deficit in knee flexion strength, with Pearson correlations of 0.51, 0.57, and 0.61, respectively. Conclusion: The muscle-tendon properties of the semitendinosus and gracilis are substantially altered after harvesting, and these alterations may contribute to knee flexor weakness in the surgical limb. These deficits are more pronounced in knees with tendons that do not regenerate and are only partially offset by compensatory hypertrophy of other hamstring muscles.
Article
Background: Studies establishing the feasibility of anterior cruciate ligament (ACL) reconstruction as an outpatient procedure in France were usually conducted with hamstring tendon grafts. The objective of this study was to evaluate the outcomes of outpatient ACL reconstruction according to whether the graft was harvested from the hamstring tendons or patellar tendon. Hypothesis: Outpatient ACL reconstruction can be performed using any type of graft. Methods: A single-centre retrospective study was conducted in consecutive patients older than 16years who had primary ACL reconstruction using patellar tendon or hamstring tendons, with or without lateral tenodesis. Patients who underwent other procedures on bones or peripheral ligaments and those with a previous history of ACL reconstruction were excluded. The primary evaluation criterion was the occurrence of complications within 45days after surgery. Secondary evaluation criteria were the visual analogue scale (VAS) for pain during the first 3 postoperative days, patient satisfaction on day 3, and the IKDC and Lysholm clinical scores on day 45. Results: The analysis included 104 knees (one knee per patient). Hamstring tendons were used in 77 (74%) knees and patellar tendon in 27 (26%) knees. In the hamstring group, 2 (2.6%) patients spent the first postoperative night in the hospital and 2 others were re-admitted. No hospitalisations were recorded in the patellar-tendon group. None of the patients required revision surgery within 45days of the reconstruction procedure. None of the postoperative criteria studied showed statistically significant differences between the two groups. Discussion: ACL reconstruction can be performed on an outpatient basis using any type of graft. The main determinants of successful outpatient ACL reconstruction are a standardised clinical management strategy and an appropriate anaesthesia protocol. Level of evidence: Level IV, retrospective study.
Article
Complications/adverse events of anterior cruciate ligament (ACL) surgery are underreported, despite pooled level 1 data in systematic reviews. All adverse events/complications occurring within a 2-year postoperative period after primary ACL reconstruction, as part of a large randomized clinical trial (RCT), were identified and described. Prospective, double-blind randomized clinical trial. Patients and the independent trained examiner were blinded to treatment allocation. University-based orthopedic referral practice. Three hundred thirty patients (14-50 years; 183 males) with isolated ACL deficiency were intraoperatively randomized to ACL reconstruction with 1 autograft type. Graft harvest and arthroscopic portal incisions were identical. Patients were equally distributed to patellar tendon (PT), quadruple-stranded hamstring tendon (HT), and double-bundle (DB) hamstring autograft ACL reconstruction. Adverse events/complications were patient reported, documented, and diagnoses confirmed. Two major complications occurred: pulmonary embolism and septic arthritis. Twenty-four patients (7.3%) required repeat surgery, including 25 separate operations: PT = 7 (6.4%), HT = 9 (8.2%), and DB = 8 (7.3%). Repeat surgery was performed for meniscal tears (3.6%; n = 12), intra-articular scarring (2.7%; n = 9), chondral pathology (0.6%; n = 2), and wound dehiscence (0.3%; n = 1). Other complications included wound problems, sensory nerve damage, muscle tendon injury, tibial periostitis, and suspected meniscal tears and chondral lesions. Overall, more complications occurred in the HT/DB groups (PT = 24; HT = 31; DB = 45), but more PT patients complained of moderate or severe kneeling pain (PT = 17; HT = 9; DB = 4) at 2 years. Overall, ACL reconstructive surgery is safe. Major complications were uncommon. Secondary surgery was necessary 7.3% of the time for complications/adverse events (excluding graft reinjury or revisions) within the first 2 years. Level 1 (therapeutic studies). This article reports on the complications/adverse events that were prospectively identified up to 2 years postoperatively, in a defined patient population participating in a large double-blind randomized clinical trial comparing PT, single-bundle hamstring, and DB hamstring reconstructions for ACL rupture.
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Although recurrent hamstring injury is a frequent problem with a significant impact on athletes, data on factors determining the risk for a recurrent hamstring injury are scarce. To systematically review the literature and provide an overview of risk factors for re-injury of acute hamstring muscle injuries. Prospective studies on risk factors for re-injury following acute hamstring injuries were systematically reviewed. Medical databases and reference lists of the included articles were searched. Two reviewers independently selected potential studies and assessed methodological quality; one reviewer extracted the data. A best-evidence synthesis of all studied risk factors was performed. Of the 131 articles identified, five prospective follow-up studies fulfilled our inclusion criteria. These studies reported a recurrence incidence of 13.9-63.3% in the same playing season up to 2 years after initial injury. Limited evidence for three risk factors and one protective factor for recurrent hamstring injury was found; patients with a recurrent hamstring injury had an initial injury with a larger volume size as measured on MRI (47.03 vs 12.42 cm(3)), more often had a Grade 1 initial trauma (Grade 0: 0-30.4%; Grade 1: 60.9-100%; Grade 2: 8.7%) and more often had a previous ipsilateral anterior cruciate ligament (ACL) reconstruction (66.6% vs 17.1%) independent of graft selection. Athletes in a rehabilitation programme with agility/stabilisation exercises rather than strength/stretching exercises had a lower risk for re-injury (7.7% vs 70%). No significant relationship with re-injury was found for 11 related determinants. There was conflicting evidence that a larger cross-sectional area is a risk factor for recurrent hamstring injury. There is limited evidence that athletes with a larger volume size of initial trauma, a Grade 1 hamstring injury and a previous ipsilateral ACL reconstruction are at increased risk for recurrent hamstring injury. Athletes seem to be at lower risk for re-injury when following agility/stabilisation exercises.
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Investigations into hamstring strain injuries at the elite level exist in sports such as Australian Rules football, rugby, and soccer, but no large-scale study exists on the incidence and circumstances surrounding these injuries in the National Football League (NFL). Injury rates will vary between different player positions, times in the season, and across different playing situations. Descriptive epidemiology study. Between 1989 and 1998, injury data were prospectively collected by athletic trainers for every NFL team and recorded in the NFL's Injury Surveillance System. Data collected included team, date of injury, activity the player was engaged in at the time of injury, injury severity, position played, mechanism of injury, and history of previous injury. Injury rates were reported in injuries per athlete-exposure (A-E). An athlete-exposure was defined as 1 athlete participating in either 1 practice or 1 game. Over the 10-year study period 1716 hamstring strains were reported for an injury rate (IR) of 0.77 per 1000 A-E. More than half (51.3%) of hamstring strains occurred during the 7-week preseason. The preseason practice IR was significantly elevated compared with the regular-season practice IR (0.82/1000 A-E and 0.18/1000 A-E, respectively). The most commonly injured positions were the defensive secondary, accounting for 23.1% of the injuries; the wide receivers, accounting for 20.8%; and special teams, constituting 13.0% of the injuries in the study. Hamstring strains are a considerable cause of disability in football, with the majority of injuries occurring during the short preseason. In particular, the speed position players, such as the wide receivers and defensive secondary, as well as players on the special teams units, are at elevated risk for injury. These positions and situations with a higher risk of injury provide foci for preventative interventions.
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Clinical Sports Medicine has been fully updated from the popular 2nd edition (2000). It is even more practical, now superbly illustrated, easy-to-read and packed with substantially updated and new material. There are samples of several chapters online including the whole "Pain in the Achilles region" chapter. This book describes a completely symptom-oriented approach to treating clinical problems.
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Sixty-eight patients were clinically evaluated preoperatively, 3, 5, 7, 9 months, 1 and 2 years after ACL reconstruction, 34 with patellar tendon graft, 34 with hamstring graft. Outcome regarding graft choice and anterior knee laxity (P = 0.04) was in favour of patellar tendon graft. Hamstring graft led to a larger laxity, 2.4 mm compared with patellar tendon graft, 1.3 mm at 1 year and 2.5 mm and 1.5 mm, respectively, at 2 years (P = 0.05). There was a significant difference in rotational knee stability in favour of the patellar tendon graft at all test occasions but 9 months. A general effect regarding graft choice and muscle torque was found at 90 degrees/s for quadriceps (P = 0.03) and hamstrings (P < or = 0.0001) and at 230 degrees/s for hamstrings (P < or = 0.0001). No treatment effect regarding graft choice and one-leg hop test, postural sway or knee function was found. No group differences in anterior knee pain were found at any of the test occasions but 2 years in favour of hamstring graft compared to patellar tendon graft (P = 0.04). Patellar tendon graft resulted in higher activity level than hamstring graft at all test occasions but 1 year (P = 0.01). Patellar tendon ACL reconstruction led to more stable knees with less anterior knee laxity and less rotational instability than hamstring ACL reconstruction. Hamstring graft patients had not reached preoperative level in hamstring torque even 2 years after ACL reconstruction. Athletes with patellar tendon graft returned to sports earlier and at a higher level than those with hamstring graft.
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Many different methods of evaluating disability after knee ligament injury exist. Most of them differ in design. Some are based on only patients' symptoms. Other include patients' symptoms, activity grading, performance in a test, and clinical findings. The rating in these evaluating systems can be either numerical, as in a score, or binary, with yes/no answers. Comparison between a symptom-related score and a score of more complex design showed that the symptom-related score gave a more differentiated picture of the disability. It was also shown that the binary rating system gave less detailed information than a score and that differences in a binary rating can depend on at what level the symptoms are regarded as "significant." A new activity grading scale, where work and sport activities were graded numerically, was constructed as complement to the functional score. When evaluating knee ligament injuries, stability testing, functional knee score, performance test, and activity grading are all important. However, the relative importance varies during the course of treatment, and therefore they should not all be included in one and the same score.
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To prospectively establish risk factors for hamstring muscle strain injury using magnetic resonance imaging (MRI) to define the diagnosis of posterior thigh injury. In a prospective cohort study using two elite Australian Rules football clubs, the anthropometric characteristics and past clinical history of 114 athletes were recorded. Players were followed throughout the subsequent season, with posterior thigh injuries being documented. Hamstring intramuscular hyperintensity on T2 weighted MRI was required to meet our criteria for a definite hamstring injury. Statistical associations were sought between anthropometric and previous clinical characteristics and hamstring muscle injury. MRI in 32 players showed either hamstring injury (n = 26) or normal scans (n = 6). An association existed between a hamstring injury and each of the following: increasing age, being aboriginal, past history of an injury to the posterior thigh or knee or osteitis pubis (all p<0.05). These factors were still significant when players with a past history of posterior thigh injury (n = 26) were excluded. Previous back injury was associated with a posterior thigh injury that looked normal on MRI scan, but not with an MRI detected hamstring injury. Hamstring injuries are common in Australian football, and previous posterior thigh injury is a significant risk factor. Other factors, such as increasing age, being of aboriginal descent, or having a past history of knee injury or osteitis pubis, increase the risk of hamstring strain independently of previous posterior thigh injury. However, as the numbers in this study are small, further research is needed before definitive statements can be made.
Conference Paper
Background: Patellar and hamstring tendon autografts are the most frequently used graft types for anterior cruciate ligament reconstruction, but few direct comparisons of outcomes have been published. Hypothesis: There is no difference in outcome between the two types of reconstruction. Study Design: Prospective randomized clinical trial. Methods: After isolated anterior cruciate ligament rupture, 65 patients were randomized to receive either a patellar tendon or a four-strand hamstring tendon graft reconstruction, and results were reviewed at 4, 8, 12, 24, and 36 months. Results: Pain on kneeling was more common and extension deficits were greater in the patellar tendon group. There were greater quadriceps peak torque deficits in the patellar tendon group at 4 and 8 months but not thereafter. In the hamstring tendon group, active flexion deficits were greater from 8 to 24 months, and KT-1000 arthrometer side-to-side differences in anterior knee laxity at 134 N were greater. Cincinnati knee scores, International Knee Documentation Committee ratings, and rates of return to preinjury activity levels were not significantly different between the two groups. Conclusions: Both grafts resulted in satisfactory functional outcomes but with increased morbidity in the patellar tendon group and increased knee laxity and radiographic femoral tunnel widening in the hamstring tendon group. (C) 2003 American Orthopaedic Society for Sports Medicine.
Article
The role of anthropometric measurements in the prediction of hamstring autograft size remains unclear. In this internal review board - approved study, we evaluated medical records for patients receiving anterior cruciate ligament (ACL) reconstruction with hamstring autograft at our institution between 2006 and 2008. One hundred and thirty-two patients received hamstring autografts. Correlation coefficients and step-wise multiple linear regression analysis were used to determine the relationships between sex, age, height, body mass index (BMI), and hamstring graft diameter. Women had significantly smaller grafts than men (P < .00001). Twenty-four patients had grafts less than 7 mm in diameter and 18 of those patients were female. Age and BMI did not correlate with graft diameter in women. Height correlated to graft diameter in women (P = .002, R(2) = 0.14). Women shorter than 65 in had significantly smaller graft diameters (mean [SD], 6.94 [0.45] mm), than those women 65 in and taller (mean [SD], 7.20 0.49] mm; (P = .03). Age and height did not correlate with graft size in men. BMI greater than 25 kg/m(2) correlated with larger graft diameter, but BMI less than 18 kg/m(2) did not predict graft sizes less than 7 mm. Therefore, alternative graft options should be considered in women less than 65 in tall.
Article
The purpose of this study was to investigate hamstring strength after harvest of 1 or 2 hamstring tendons for anterior cruciate ligament reconstruction. We recruited 50 individuals who had returned to regular sporting activity to participate in a comparative study at a mean of 32.5 months after anterior cruciate ligament reconstructive surgery (30 in semitendinosus-gracilis group and 20 in semitendinosus group). Isokinetic hamstring strength (at 60 degrees/s and 180 degrees/s with the peak torque and torque produced at 60 degrees, 90 degrees, and 105 degrees of knee flexion recorded) and isometric hamstring strength (at 30 degrees, 90 degrees, and 105 degrees of knee flexion) were measured, and the standing knee flexion angle was used to evaluate functional hamstring strength recovery. No significant differences between the groups were found in any of the isometric or isokinetic strength measures or in the standing knee flexion angle. No relation was found between the standing knee flexion angle and the isometric hamstring strength results obtained at 105 degrees of knee flexion (r(2) = 0.034). These findings show that the choice of hamstring tendon graft-that is, semitendinosus alone or semitendinosus and gracilis-is unlikely to significantly influence postoperative hamstring strength outcomes in athletes returning to sports postoperatively. Both graft choices showed strength deficits of between 3% and 27% compared with the nonoperated limb, indicating that hamstring strength deficits persist despite successful completion of rehabilitation. The results also show that the standing knee flexion angle should not be used as a surrogate clinical measure of hamstring strength. Level III, retrospective comparative study.
Article
The use of autologous grafts such as the quadrupled semitendinosus and gracilis tendon is very common in anterior cruciate ligament (ACL) reconstruction. The diameter of such grafts can be variable and thus unpredictable prior to surgery. In this study, we hypothesized that parameters such as gender, height, age, and body mass index (BMI) can be used pre-operatively to reveal the true graft diameter. All hamstring ACL reconstructions from 1994 to 2002 were reviewed. 536 cases (302 females, 234 males) met the inclusion criteria. Quadruple hamstring constructs and femoral tunnel diameters were measured using 1mm increment graft sizers. Pre-operative measures of height, weight, body mass index, gender, and age were obtained. Multiple regression analysis was used to build a predictive model of the quadruple hamstring graft diameter. The results of the study demonstrated that males had significantly larger grafts than females (8.1+/-0.8 vs. 7.5+/-0.6mm). Multiple regression analysis on the entire group showed that pre-operative height (p<0.0002) and gender (p<0.0047), but not age (p<0.06) or weight (p<0.019) were significant predictors of graft diameter. Height (p<0.0001) was a specific predictor solely in men. In females, none of the pre-operative measures were predictive of graft diameters. Patient height and gender can be used as pre-operative indicators of in vivo quadrupled hamstring graft diameter. Regardless of other variables, 42% of females will have tunnel diameters of 7mm or less. An alternative graft choice should be discussed pre-operatively if graft sizes may be of concern for the tall and large female patients.
Article
Hamstring muscles play a major role in knee-joint stabilization after anterior cruciate ligament (ACL) injury. Weakness of the knee extensors after ACL reconstruction with patellar tendon (PT) graft, and in the knee flexors after reconstruction with hamstring tendons (HT) graft has been observed up to 2 years post surgery, but not later. In these studies, isokinetic muscle torque was used. However, muscle power has been suggested to be a more sensitive and sport-specific measures of strength. The aim was to study quadriceps and hamstring muscle power in patients with ACL injury treated with surgical reconstruction with PT or HT grafts at a mean of 3 years after surgery. Twenty subjects with PT and 16 subjects with HT grafts (mean age at follow up 30 years, range 20-39, 25% women), who were all included in a prospective study and followed the same goal-based rehabilitation protocol for at least 4 months, were assessed with reliable, valid, and responsive tests of quadriceps and hamstring muscle power at 3 years (SD 0.9, range 2-5) after surgery. The mean difference between legs (injured minus uninjured), the hamstring to quadriceps (H:Q, hamstring divided by quadriceps) ratio, and the limb symmetry index (LSI, injured leg divided by uninjured and multiplied by 100) value, were used for comparisons between the groups (analysis of variance). The mean difference between the injured and uninjured legs was greater in the HT than in the PT group for knee flexion power (-21.3 vs. 7.7 W, p = 0.001). Patients with HT graft had lower H:Q ratio in the injured leg than the patients with PT graft (0.63 vs. 0.77, p = 0.012). They also had lower LSI for knee flexion power than those in the PT group (88 vs. 106%, p < 0.001). No differences were found between the groups for knee extension power. The lower hamstring muscle power, and the lower hamstring to quadriceps ratio in the HT graft group than in the PT graft group 3 years (range 2-5) after ACL reconstruction, reflect imbalance of knee muscles after reconstruction with HT graft that may have a negative effect on dynamic knee-joint stabilization.
Article
Apparent regeneration of the tendons of the semitendinosus and gracilis muscles after their use for anterior cruciate ligament reconstruction was noted during routine follow-up of 225 patients. From this group, four patients were selected for thorough examination, including magnetic resonance imaging, electromyographic studies, strength testing, and clinical examination. The results demonstrate that these tendons appear to regrow and are probably functional.
Article
Eighty consecutive patients with chronic laxity due to a torn ACL underwent arthroscopically assisted recon struction with either autogenous patellar tendon or doubled semitendinosus and gracilis tendons. Recon structions were performed on a one-to-one alternating basis. Preoperatively, no significant differences be tween the two groups were noted with respect to age, sex, level of activity, and degree of laxity (chi square analysis). A standard rehabilitation regimen was used for all patients after surgery including immediate pas sive knee extension, early stationary cycling, protected weightbearing for 6 weeks, avoidance of resisted ter minal knee extension until 6 months, and return to activity at 10 to 12 months postoperatively. Seventy-two patients were evaluated at a minimum of 24 months postoperatively (range, 24 to 40 months). No significant differences were noted between groups with respect to subjective complaints, functional level, or objective laxity evaluation, including KT-1000 meas urements. Seventeen of 72 patients (24%) experienced anterior knee pain after ACL reconstruction. Overall, 46 of 72 patients (64%) returned to their preinjury level of activity. Mean KT-1000 scores were 1.6 ± 1.4 mm for the patellar tendon group and 1.9 ± 1.3 mm for the semitendinosus and gracilis tendons group. This study did find a statistically significant weakness in peak hamstrings torque at 60 deg/sec when recon struction was performed with double-looped semiten dinosus and gracilis tendons.
Article
We feel that some of the current prejudice against use of hamstring tendon grafts for ACL reconstruction has not been justified if one critically reviews the literature. In this article, we have tried to provide the reader with our current indications, present our current surgical technique, and review some of the outcome studies involving use of the hamstring tendons for ACL reconstruction. We also feel that some of the poor results of hamstring tendon ACL reconstructions previously reported resulted from the use of inadequate strength grafts (single-stranded grafts) and lack of rigid fixation on both ends of the graft (usually secondary to inadequate graft length). We feel that the technique described in this article addresses both of these issues. It is our clinical impression that, in appropriately selected patients, this technique produces stability and functional outcome similar to that obtained with patellar tendon grafts but results in less postoperative pain, a quicker return of quadriceps muscle function, and less donor site morbidity.
Article
The purposes of this study were to compare operated and nonoperated knees after anterior cruciate ligament reconstruction using the semitendinosus tendon and a polypropylene ligament augmentation device, and to determine the interrelationships among strength, knee stability, and current activity levels. Isokinetic tests for knee flexion (prone position) and extension (sitting position) strength during concentric-eccentric muscle action cycles were completed at 60 and 180 deg/sec angular velocities, and passive anterior displacement were determined for 15 male and 15 female patients (mean age, 27 +/- 8 years; mean time since surgery, 21 +/- 3 months). With the exception of eccentric muscle actions during knee extension, peak torque and work done were significantly greater on the nonoperated leg (P < 0.05). Passive anterior displacement was significantly greater in the operated than the nonoperated knee (P < 0.01). Strength measurements tended to be modestly related to current activity level (R > 0.40 in 24 of 32 correlations; P < 0.05), whereas anterior displacement was not related to current activity level (R = -0.19, operated knee; R = -0.09, nonoperated knee; P > 0.05). Greater emphasis should be directed toward strengthening the knee flexors and knee extensors after this surgery. Although joint-specific tests (completed actively via isokinetic dynameter) are more related to activity levels than are knee laxity tests (completed passively via knee arthrometer), neither test should be relied on as the only predictor of activity level in this patient population.
Article
The length and cross-sectional area of human semitendinosus and gracilis tendons were measured in both single- and multi-strand configurations for the purpose of anterior cruciate ligament graft preparation. The average lengths of the semitendinosus and the gracilis tendons were 235 +/- 20 mm (mean +/- SD) and 200 +/- 17 mm, respectively. The cross-sectional area of a doubled semi-tendinosus tendon (two strands) was significantly less than that of a 10-mm-wide patellar tendon graft (P < 0.001). The cross-sectional area of the tripled semitendinosus tendon (three strands) and the 10-mm-wide patellar tendon were similar. Doubling of the combined semitendinosus and gracilis tendons (four strands) and tripling of this combination (six strands) resulted in a significantly greater cross-sectional area in comparison to the 10-mm-wide patellar tendon (P < 0.05, four strands; P < 0.001 six strands). This investigation demonstrates that anterior cruciate ligament grafts fashioned using multiple-strand combinations of the semitendinosus and gracilis tendons result in a cross-sectional area that is comparable to the bone-patellar tendon-bone graft. This is an important finding since cross-sectional area reflects the intra-articular volume of collagenous tissue. This information should be helpful to surgeons considering using the hamstring tendons as an anterior cruciate ligament graft.
Article
This study evaluates the morbidity of harvest of both the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction on nine patients at a minimum of 3 year follow-up. Specifically, the effect on knee function, knee extension and flexion strength, the size of the individual posterior thigh muscles, and the extent of retraction of the semitendinosus and gracilis tendons were evaluated. At final follow-up, each patient was evaluated using the following functional scales: International Knee Documentation Committee (IKDC), Hospital for Special Surgery (HSS), Lysholm, and Tegner. Each patient also had a dynamometer evaluation and a comprehensive magnetic resonance imaging study of both the operated and nonoperated knees. The average functional evaluation scores were: HSS-47.9, Lysholm-88, and Tegner-0.27. The average percent quadriceps and hamstring strength of the operated compared with the nonoperated extremities were 93.7% and 95.3%, respectively; neither decrease was significant. Magnetic resonance imaging evaluation of the cross-sectional areas of the biceps femoris, semimembranosus, and sartorius muscles of both thighs at the same level above the joint were not significantly different. The distal-most insertion of the semitendinosus and gracilis tendons after harvest were always more proximal than the nonoperated side; the average difference was 26.7 mm (range: 11 to 32 mm) for the semitendinosus (unable to calculate in three patients) and 47.1 mm (range: 17 to 72 mm) for the gracilis. We conclude that tendon harvest of the semitendinosus and gracilis muscles does not significantly compromise function and strength despite a more proximal insertion of the retracted tendons. In addition, the majority of cases demonstrated some but never complete regrowth or scar formation of these tendon remnants.
Article
It has recently been shown that graft fixation close to the ACL insertion site is optimal in order to increase anterior knee stability. Hamstring tendon fixation using interference screws offers this possibility and a round threaded titanium interference screw has been previously developed. The use of a round threaded biodegradable interference screw may be equivalent. In addition, to increase initial fixation strength, graft harvest with a distally attached bone plug may be advantageous, but biomechanical data do not exist. This study compares the initial pullout force, stiffness of fixation, and failure modes of three strand semitendinosus grafts in 36 proximal calf tibiae using either biodegradable poly-(D,L-lactide) (Sysorb; Sulzer Orthopaedics Ltd, Münsingen, Switzerland) or round threaded titanium (RCI; Smith & Nephew DonJoy, Carlsbad, CA) interference screws, harvested either without (biodegradable: group I, titanium III) or with (biodegradable: group II, titanium: group IV) attached tibial bone plugs. Maximum pullout force in group I (507 +/- 93 N) was significantly higher than in group III (419 +/- 77 N). Pullout force of bone plug fixation was significantly higher than that of direct tendon fixation (717 +/- 90 N in group II and 602 +/- 117 N in group IV). Pullout force of biodegradable fixation was significantly higher in both settings. These results indicate that initial pullout force of hamstring-tendon graft interference screw fixation can be increased by using a biodegradable interference screw. In addition, initial pullout force of hamstring-tendon graft fixation with an interference screw can be greatly increased by harvesting the graft with its distally attached tibial bone plug.
Article
Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy's tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years' follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3-4 months and 27.5% in 4-6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this technique and the possibility of guaranteeing functional behaviour in the knee.
Article
A prospective study was conducted of how the muscle strength of the donor knee is affected by harvesting of the autogenous semitendinosus tendon (St) for use as a substitute graft material in cruciate ligament reconstruction. There were 25 patients from whom only the St was harvested from the contralateral (i.e., healthy/donor) knee. Using a Biodex System II (Biodex, New York, NY), the strength of the donor knee was measured during both extension and flexion, both before and 12 months after the tendon harvesting procedure. A comparative study was made of the preharvest and postharvest values for the peak torque and peak torque angle in the isokinetic contraction. There were no statistically significant differences between the preharvest and postharvest peak torque values of the donor knee. However, the peak torque angle decreased significantly after the tendon harvest; the range of the mean decrease was from 11.7 degrees to 15.0 degrees. This indicates that there was a change to a small flexion angle (P < .05). After the tendon harvest, regardless of the applied angular velocity, more than 80% of the cases showed a change of torque curve shape in which there was no peak in the latter half, and the position of the peak was shifted to the left. In conclusion, the results of this study indicate that harvesting of the autogenous St does not affect the peak torque, but the peak torque angle during flexion of the donor knee is reduced.
Article
We measured the cross-sectional area (CSA) of the semitendinosus tendon (SMT) in 79 anterior cruciate ligament (ACL)-injured patients using magnetic resonance imaging (MRI) to scrutinize their appropriateness for ACL grafts. Measurements of the CSAs of the SMT with MRI were closely correlated with intraoperative direct measurement (y = 0.697). The mean CSAs of the SMT measured with MRI ranged from 6.3 to 15.0 mm2 with a mean of 10.1+/-2.1 mm2. The CSA of the SMT measured with MRI proved to be a useful indicator to determine preoperatively whether the SMT graft would be of adequate dimensions (7 mm or more in diameter, 60 mm or more in length) for ACL reconstruction. If the CSA of the SMT was more than 11 mm2, a sufficiently thick and long graft could be prepared with a tripled or quadrupled SMT in 89% of cases. We conclude that tissue CSA measurements using MRI could potentially be implemented as a useful tool for determining the most appropriate donor autograft tissue preoperatively, thus minimizing harvest-site morbidity.
Article
Utilisation of the semitendinosus and gracilis tendons in reconstruction of the anterior cruciate ligament (ACL) has become more common during the last few years. In recent studies a regeneration potential in the harvested tendons has been observed. In this study, 11 consecutive patients who underwent ACL reconstruction with a quadruple semitendinosus graft were examined 6-12 months postoperatively by MRI. Another two patients were examined within 2 weeks after surgery. The median age of the patients was 24 years and there were 8 males and 3 females. The right knee was involved in six patients and the left knee in five. A low-field 0.2 Tesla Siemens open MRI was used for examinations and T1 and T2 weighted transaxial sequences over the thigh and the knee joint were performed. In some instances, additional sagittal sequences were used. ROI analysis of the pixel value of the signal and area determinations on transaxial sequences was performed for both the involved and the healthy side. In 8 of the 11 patients examined 6-12 months postoperatively, a regeneration of the semitendinosus tendon with normal anatomical topographies to the level of the tibial plateau was found. Three of these eight patients were analysed more distally and fusion of the semitendinosus and gracilis tendons was found approximately 30 mm below the joint line before they inserted as a "conjoined tendon" into the pes anserinus. At the mid-thigh level, the semitendinosus muscle had a smaller area and a higher signal than that on the normal side. However, this difference was smaller in the patients showing normal distal tendon regeneration. This study indicates that the semitendinosus tendon has a strong potential for regeneration and that the muscle atrophy seems to be less in the patients with a more normalised distal insertion of the tendon in the pes anserinus.
Article
In a prospective study, 40 consecutive patients who underwent anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon autografts were examined pre- and postoperatively by ultrasound to investigate the anatomy of the donor site before and after the harvest of the tendons. The patients underwent ultrasonography at 2 weeks and 1, 2, 3, 6, 12, 18, and 24 months postoperatively. A total of 298 postoperative sonographic evaluations were performed. The semitendinosus tendon was imaged in the sagittal and axial planes: structure and margins were evaluated with the sagittal views; thickness and width were measured with the axial views. In all cases the following sequence of healing was documented: 2 weeks after surgery the semitendinosus tendon site was occupied by an area of increased thickness and decreased echogenicity, suggesting the presence of traumatic edema of the soft tissue surrounding the tenotomy. At 1 month, an irregular hypoechoic structure appeared in a near-anatomic position; at 2 months after surgery, thickness, width, and cross-sectional area of this structure were significantly greater than preoperatively. The amount of regenerated tissue increased up to that seen in the tissue of the 6-month examinations, which also showed a more uniform echostructure. The scans performed at 1 year showed distinct edges and reduction in thickness and width. At 18 and 24 months the echogenicity of the structure occupying the donor site was very similar to that of the normal semitendinosus tendon. However, this structure was clearly identified about 4 cm proximal to the pes anserinus, revealing a more proximal insertion of the regenerated semitendinosus tendon.
Article
The purpose of this study was to examine the strength of the knee flexors and knee extensors after two surgical techniques of ACL reconstruction and compare them to an age and activity level matched control group. Twenty-four subjects who had undergone ACL reconstruction greater than 1 yr previously were placed into one of two groups according to autograft donor site: patellar tendon (BPB; N = 8) and hamstring (H; N = 16), and compared with an active, control group (N = 30). Knee flexor and extensor strength was evaluated using isovelocity dynamometry (5 speeds, eccentric and concentric, 5-95 degrees ROM). Strength maps were used to graphically analyze strength over a broad operational domain of the neuromuscular system. Average strength maps were determined for each autograft group and compared with controls. A difference map (control minus graft group) and confidence (t-test) maps were used to quantitatively identify strength deficits. The combined ACL group (N = 24) revealed a global 25.5% extensor strength deficit, with eccentric regional (angle and velocity matched) deficits up to 50% of control. Strength deficits covered over 86% of the sampled strength map area (P < 0.01). These knee extensor strength deficits are greater than previously reported. In addition, the BPB group demonstrated a concentric, low velocity, knee extensor strength deficit at 60-95 degrees that was not observed in the H group. Significant graft site dependent, regional knee flexor deficits of up to 50% of control were observed for the H group. Strength deficits localized to specific contraction types and ranges of motion were demonstrated between the ACL and control groups that were dependent upon autograft donor site. Postoperative rehabilitation protocols specific to these deficits should be devised.
Article
The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hamstring graft harvest site after harvesting the hamstring tendons to reconstruct a torn anterior cruciate ligament (ACL). Case series. We performed MRI on 21 patients who had previously undergone hamstring harvest and ACL reconstruction. Twenty of the patients (7 female and 13 male; mean age, 37 years; range, 16 to 84 years), all volunteers, were selected from a series of 45 ACL reconstructions performed by the senior author during a 20-month period. Another patient, a 32-year-old man, underwent ACL reconstruction elsewhere 32 months before. Both the semitendinosus and gracilis tendons were harvested in all cases. All MRIs were obtained on a 1.5-T magnet and were prospectively evaluated by 2 experienced musculoskeletal radiologists who were blinded to the time interval between graft harvest and MRI. Two weeks after graft harvest, MRI showed ill-defined intermediate signal on T1-weighted images and increased signal on T2-weighted images, consistent with fluid in the harvest site, with no discernable tendon. At 6 weeks, structures were seen at the level of the superior pole of the patella that had morphology and signal characteristics similar to native tendon. By 3 months, structures with normal morphology and signal characteristics were seen to the level of the joint line, and by 12 months, to the level of 1 to 3 cm above that of the tibial attachment. At 32 months, the tendons appeared on MRI to normalize to a level of 1 to 2 cm above their tibial attachment. Following hamstring tendon harvest, MRI demonstrates an apparent regeneration of tendons beginning proximally and extending distally over time.
Article
Recently, the surprising observation has been made, supported by clinical and MRI findings, that the semitendinosus tendon can regenerate after being harvested in its whole length and thickness for anterior cruciate ligament reconstruction. We studied 6 patients with previous anterior cruciate ligament reconstruction, using a quadruple semitendinosus tendon autograft. In 5 of these, physical examination and MRI showed that the tendond had regenerated. In all 6 patients, the findings were documented macroscopically by open surgical exploration and in the 5 regenerated tendons, also morphologically by biopsies. Macroscopically, histologically and immunohistochemically the regenerated tendons closely resembled normal ones with focal scar-like areas. Our present findings and earlier studies show that full length and thickness harvesting of the semitendinosus tendon in most cases result in full-length tendon regeneration with tissue closely resembling the normal tendon.
Article
To evaluate the fate of the hamstring muscles in general and the semitendinosus muscle in particular, after anterior cruciate ligament (ACL) reconstruction with an autologous semitendinosus tendon graft from the ipsilateral side. Type of Study: Prospective consecutive case series investigation. Included were 16 consecutive patients, 14 male and 2 female, with a mean age of 26 years. The inclusion criterion was chronic unilateral ACL insufficiency with no concomitant knee ligament injuries. ACL reconstruction was performed with a quadruple semitendinosus tendon graft using the EndoButton technique (Acufex, Mansfield, MA). Intraoperatively, muscle specimens were taken from the semitendinosus muscle on the harvested side. Follow-up at a minimum of 6 months included clinical examination, isokinetic strength performance, magnetic resonance imaging (MRI) of the thigh and knee, and ultrasound-guided muscle biopsy procurement from the semitendinosus muscle for histochemical and enzymatic analyses. Of the patients, 75% showed regeneration of their semitendinosus tendons. The neotendons all inserted below the knee joint where they had fused with the gracilis tendon to a conjoined tendon inserting in the pes anserinus. The semitendinosus muscle had a smaller cross-sectional area on the operated side but none showed total atrophy. Less atrophy was present in the patients with a regenerated semitendinosus neotendon compared with those without regeneration (P =.029). In the latter group the semimembranosus muscle seemed to compensate for this with hypertrophy (P =.019). Cross-sectional muscle fiber areas, the relative number of each fiber type and oxidative potential as estimated by citrate synthase activity, showed no significant differences between the operated and nonoperated legs. The isokinetic strength of the hamstrings and quadriceps was significantly lower in the operated leg than in the nonoperated leg. With this surgical technique, the semitendinosus muscle can recover and the tendon has, according to the MRI images, a great potential to regenerate after its removal.
Article
The authors review the current knowledge on donor site-related problems after using different types of autografts for anterior cruciate ligament (ACL) reconstruction and make recommendations on minimizing late donor-site problems. Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for patients. The selection of graft, surgical technique, and rehabilitation program can affect the severity of pain that patients experience. The loss or disturbance of anterior sensitivity caused by intraoperative injury to the infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site discomfort and an inability to kneel and knee-walk. The patellar tendon at the donor site has significant clinical, radiographic, and histologic abnormalities 2 years after harvest of its central third. Donor-site discomfort correlates poorly with radiographic and histologic findings after the use of patellar tendon autografts. The use of hamstring tendon autografts appears to cause less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also appears to be a regrowth of the hamstring tendons within 2 years of the harvesting procedure. There is little known about the effect on the donor site of harvesting fascia lata and quadriceps tendon autografts. Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction using patellar tendon autografts. Reharvesting the patellar tendon cannot be recommended due to significant clinical, radiographic, and histologic abnormalities 2 years after harvesting its central third. It is important to regain full range of motion and strength after the use of any type of autograft to avoid future anterior knee problems. If randomized controlled trials show that the long-term laxity measurements following ACL reconstruction using hamstring tendon autografts are equal to those of patellar tendon autografts, we recommend the use of hamstring tendon autografts because there are fewer donor-site problems.
Article
This study assessed the quadriceps and hamstring strength before and 6 months after anterior cruciate ligament (ACL) reconstructive surgery using the hamstrings and related the findings to functional performance. Six months after surgery is a critical time for assessment as this is when players are returning to sport. Maximum isokinetic strength of 31 patients with complete unilateral ACL ruptures was measured at speeds of 60 degrees and 120 degrees per second. Functional assessment included the single hop, the triple hop, the shuttle run, side-step and carioca tests. All patients underwent a controlled quadriceps emphasized home-based physiotherapy program both before and after surgery. Results show that before surgery there was a 7.3% quadriceps strength deficit at 60 degrees per second compared to the uninjured leg but no hamstring strength deficit. After surgery there was a statistically significant but relatively small loss of muscle strength. The quadriceps strength deficit had increased to 12% and there was a 10% hamstring deficit. Post-operatively there was an 11% and 6.3% improvement in the hop tests, a 9% (P < 0.01) improvement in the shuttle run, a 15% (P < 0.001) improvement in the side step and a 24% (P < 0.001) improvement in the carioca tests (P < 0.001) despite the loss of muscle strength.
Article
The cross-sectional areas of individual knee flexors and isokinetic flexion measurements were evaluated using computed tomography in 13 patients following semitendinosus and gracilis tendon harvest for anterior cruciate ligament reconstruction. The atrophy of tendon-dissected muscles demonstrated variance with two peaks: >70% and <50%. In three patients whose semitendinosus and gracilis muscles displayed areas <50% of the contralateral area, the cross-sectional area of the entire flexor group and work at >75 degrees of knee flexion was 88.1% and 51.9%, respectively. Therefore, hamstring tendon harvest can induce atrophy of tendon-dissected muscles and decrease flexor function.
Article
The purpose of this study was to evaluate active knee flexion range of motion and hamstring strength following hamstring anterior cruciate ligament (ACL) reconstruction. Case control study, consecutive sample. Seventy-four consecutive patients who had undergone hamstring ACL reconstruction underwent isokinetic muscle strength testing at 2 years post surgery. Measurements of the maximum standing active knee flexion angle with the hip extended were also taken. During isokinetic testing, we evaluated flexion torque at 90 degrees of knee flexion, in addition to the peak flexion torque. We further compared these parameters of muscle strength around the knee for the patients in whom only semitendinosus tendon was harvested as a graft source (ST group), and those from whom the semitendinosus tendon and the gracilis tendon were harvested (ST/G group). Isokinetic testing showed that, in both the ST and ST/G groups, the knee flexor strength of the involved leg was less effectively restored at 90 degrees of knee flexion than at the angle at which the peak torque was generated. Conversely, no significant difference was seen in the side-to-side ratio in either the peak flexion torque or the 90 degrees flexion torque between the groups. The side-to-side ratio in mean maximum standing knee flexion angle was significantly lower in the ST/G group than in the ST group. This study suggests that the loss of knee flexor strength following the harvest of the hamstring tendons may be more significant than has been previously estimated. Furthermore, multiple tendon harvest may affect the range of active knee flexion.
Article
The use of blunt-threaded titanium interference screws for arthroscopic-assisted fixation of a quadruple-strand hamstring anterior cruciate ligament (ACL) reconstruction has recently been reported. However, the pitfalls of the low medial portal technique, rehabilitation protocol, and long-term results have not. The purpose of this multicenter study was to prospectively evaluate this technique's application to ACL instability in symptomatic patients as well as to develop a standardized rehabilitation protocol. Observation cohort study. One hundred-twenty patients had quadruple hamstring ACL reconstructions, followed the study protocol, and were seen at 2 years follow-up. They were evaluated using Lysholm score, Lachman test, anterior drawer test, pivot-shift test, KT-1000, effusion assessment, and the Tegner Sports Activity Scale. The average Lysholm score improved 42 points; Lachman test, effusion assessment, anterior drawer test, KT-1000, and Tegner Sports Activity Scale scores all improved. Of 120 ACL reconstructions, 5 failed. Of these, 3 failed from new late injury, 1 from technical error, and 1 from patient nonadherence to rehabilitation protocol. Some anterior knee pain was present in 30% of patients, and 22% had at some time experienced hamstring pain that did not interfere with athletic activity. This multicenter study reports success with quadruple hamstring ACL reconstruction using the low medial portal technique. Specific pitfalls and a rehabilitation protocol are also discussed. Low medial portal position is critical in successful surgery. Variations in screw size to accommodate the variation in graft construct size are also recommended.
Article
This prospective study examined 50 patients who underwent ACL surgery using hamstring tendons with a modification including intra- and extra-articular reconstruction. All patients were athletes competing at a high level in various sports. Full return to sports was allowed at 4 months. IKDC score and KT-2000 were used for assessing clinical outcome at a mean of 6.4 years (5-7 years) Resumption of sport, Tegner activity score, and isokinetic test were also used. The IKDC score showed 92% of normal or nearly normal knees. Of the 50 patients 48 regained full extension, and only two had extension deficit between 0 degrees and 3 degrees. KT evaluation was less than 3 mm in 38 cases (76%), 3-5 mm in 9 (18%), and more than 5 mm in 3 (6%). In 90% of cases the patient resumed sport at the same level. The mean Tegner activity score was 8.1 (5-10). The isokinetic test showed no deficit for hamstring and quadriceps muscles. Removal of staples was necessary in eight cases (16%) due to femoral lateral bursitis. Acute reconstruction had significantly better clinical assessment of abnormal laxity and KT value. Men had significantly better results then women. This technique demonstrated a high reliability, low morbidity, low functional deficit and fast recovery using hamstring grafts.
Article
Forty-three patients who had undergone an anterior cruciate ligament (ACL) reconstruction using a doubled semitendinosus and gracilis graft were prospectively reviewed at 5-year follow-up. All had suffered subacute or chronic tears of the ligament. At surgery, the femoral tunnel was drilled first through the antero-medial portal. The correct position of the femoral and tibial guide wire was checked fluoroscopically. A cortical fixation to the bone was achieved in the femur with a Mitek anchor, directly passing the two tendons in the slot of the anchor, and in the tibia with an RCI screw, supplemented with a spiked washer and bicortical screw. Rehabilitation was aggressive, controlled and without braces. The International Knee Documentation Committee (IKDC) form, KT-1000 arthrometer, and Cybex dynamometer were employed for clinical evaluation. A radiographic study was also performed. At the 5-year follow-up all the patients had recovered full range of motion and 2% of them complained of pain during light sports activities. Four patients (9.5%) reported giving-way symptoms. The KT-1000 side-to-side difference was on average 2.1 mm at 30 lb, and 68% of the knees were within 2 mm. The final IKDC score showed 90% satisfactory results. There was no difference between the 2-year and 5-year evaluations in terms of stability. Extensor and flexor muscle strength recovery was almost complete (maximum deficit 5%). Radiographic study showed a tunnel widening in 32% of the femurs and 40% of the tibias. A correlation was found between the incidence of tibial tunnel widening and the distance of the RCI screw from the joint (the closer the screw to the joint, the lower the incidence of widening). In conclusion, we can state that, using a four-strand hamstring graft and a cortical fixation at both ends, we were able to achieve satisfactory 5-year results in 90% of the patients.
Article
The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high-performance athletes, and hamstring autografts and allografts have some relative advantages for lower-demand individuals. No current indications exist for synthetic ligaments.
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