2025 ISAKOS Biennial Congress Paper
ACL Reconstruction With Quadruple Semitendinosus Graft Versus Double Semitendinosus and Gracilis Graft: 5–10-Year Preliminary Results From a Prospective Randomized Controlled Trial
Ingunn Fleten Mo, MSc NORWAY
Thomas Harlem, MD, Riverside, Connecticut UNITED STATES
Anne Gro Heyn Faleide, MSc, Bergen NORWAY
Torbjørn Strand, MD, Bergen NORWAY
Søren Vindfeld, MD, Bergen NORWAY
Eirik Solheim, MD, PhD, Bergen NORWAY
Per-Henrik Randsborg, MD, PhD, Lørenskog, Akershus NORWAY
Eivind Inderhaug, MD, PhD, MPH, Bergen NORWAY
Haraldsplass Deaconess Hospital, Bergen, Vestland, NORWAY
FDA Status Cleared
Summary
Both the quadrupled semitendinosus graft and the doubled semitendinosus and gracilis graft technique significantly improve knee function and stability from preoperatively to 5-10 years after surgery, with no significant differences in outcomes or increased risk of recurrent instability or revision surgery between groups.
Abstract
Background
Worldwide, hamstring tendons are the most used graft source for anterior cruciate ligament reconstruction. Usually, both the semitendinosus and gracilis tendons are harvested to create a new robust graft. An alternative to this technique is the "all-inside" technique, where only a quadrupled semitendinosus tendon is used. Studies with a short follow-up period have shown that the two techniques give equivalent results when it comes to self-reported knee function and stability, but we know little about long-term results comparing these techniques. Two-year results from this study have already been reported, showing no differences between groups, but with a tendency towards increased translation in the “all-inside” group. It has also been raised concerns to if the "all-inside" technique increases the risk of recurrent instability and revision surgery.
Material And Method
In this randomized controlled trial, 98 patients were randomized to either quadrupled semitendinosus graft or doubled semitendinosus and gracilis graft. The group size was calculated from clinically meaningful change in the primary outcome measure International Knee Documentation Committee 2000 Subjective knee Form (IKDC). Secondary outcome measures were clinical stability measured by Lachman, Pivot shift and KT1000. Preoperatively, after two and 5-10 years, the IKDC SF, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale (TAS) were obtained, and a clinical examination (Lachman, pivot-shift, KT1000) was carried out. In addition, the number of re-injuries and re-operations was evaluated at post-operative measurement points. T-tests and chi-square tests were performed to examine group differences.
Results
Seventy-four patients have so far completed 5-10 years of follow-up, 38 patients in the one-graft group and 36 patients in the group with two grafts. There were no demographic differences between the groups at baseline. The average follow-up time was 7.7 years (8.5 in the single-graft group and 7 in the two-graft group). Both groups had significant improvement in self-reported function and clinical stability from baseline to 5-10 years postoperatively. There were no significant differences between the groups at the last follow-up time. So far, 49 secondary interventions have been carried out, including 9 revisions. At diagnostic arthroscopy, 12 ACL grafts were described as insufficient, equally distributed between the two groups. Three patients have injured the opposite ACL since the primary operation.
Conclusion
Both surgical techniques result in significantly improved knee function 5-10 years after anterior cruciate ligament reconstruction. There were no significant differences between the two surgical techniques in self-reported function or clinical stability. There is no increased risk of recurrent instability and revision surgery when using the "all-inside" technique.