Summary

Primary ACL reconstruction using tibial attachment preserving quadrupled hamstring graft is a simple and reproducible technique with an extremely low failure and complication rate and that gives excellent clinical and functional outcomes, irrespective of the graft diameter.

Abstract

Introduction-Recent literature supports the preservation of tibial attachment of hamstring grafts to enhance ‘‘ligamentization’’ process and prevent the potential problems of a free graft such as pull-out or rupture in the early post-operative period. The aim of this study is to present our results of primary ACL reconstruction with preservation of the tibial attachment of the hamstring grafts along with loop-stitched quadrupled hamstring grafts fixed with suspensory fixation on the femoral side and an interference screw and a staple on the tibial side, and determine if the graft diameter influences the failure rate and patient-reported outcome scores.

Methodology-Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Paired two-tailed student t-tests and ANOVA tests were employed for statistical analysis.

Results- 64 cases (47 males, 17 females) with a mean BMI of 26.3 and mean age of 30.2 years were included. Mean graft length and diameter of quadrupled semitendinosus and gracilis tendons was 110 mm and 7.1mm respectively. Mean interval from injury to surgery was 11.8 months. At a mean follow-up of 3 years, 80% (n=51) had complete peri-operative PROMS scores. Mean peri-operative EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.001). At latest follow-up, there was no difference in the improvement of PROMS with regards to the graft diameter. Graft re-rupture was seen in 1 (1.5%) patient.
45 patients had associated meniscal tear with 73.3 % undergoing repair. 3 cases (4.6 %) returned to theatre including, MUA for arthrofibrosis (n=1) and meniscal repair for recurrent medial meniscus tear (n=2).

Conclusion- Primary ACL reconstruction using tibial attachment preserving quadrupled hamstring graft is a simple and reproducible technique with an extremely low failure and complication rate and that gives excellent clinical and functional outcomes, irrespective of the graft diameter. The natural tibial side insertion provides secure fixation and adds biology to the anatomic reconstruction.