Anthropometric correlation with hamstring graft size in anterior cruciate ligament reconstruction among males

Patient´s height and sex predict graft diameter. A cohort study of 4,519 patients with primary anterior cruciate ligament reconstruction using semitendinosus autograft

PURPOSE

To determine whether anthropometric measurements (height and weight), sex, age and pre-injury Tegner activity scale (TAS) were predictors of the quadrupled semitendinosus (ST) graft diameter in primary anterior cruciate ligament reconstruction (ACLR).

METHODS

A total of 4,519 patients who underwent primary ACLR with a quadrupled ST autograft were included. Anthropometric measurements (height and weight), sex, age, pre-injury TAS were collected. Correlation coefficients and multiple linear regression analysis were used to determine the relationship between graft diameter and anthropometrics measurements (height and weight), sex, age and pre-injury TAS.

RESULTS

The diameter of the quadrupled ST graft was correlated positively to height (r =.021, P <.001), age (r =.005, P <.001) and weight (r =.004, P =.001) and negatively to female sex (r = -.297, P <.001). A regression equation was estimated to predict the ST graft diameter for men as 4.245 + 0.021 x height (cm) + 0.004 x age (years) + 0.005 x weight (kg) and for women as 3.969 + 0.021 x height (cm) + 0.004 x age (years) + 0.005 x weight (kg).

CONCLUSIONS

Height, age and weight were positively correlated, whereas female sex was negatively correlated to the diameter of the quadrupled ST graft. Knowledge of these factors can be used for the preoperative estimation of the graft diameter which can be helpful for appropriate graft choice.

Tendon cross-sectional area on magnetic resonance imaging and anthropometric characteristics can be used to predict insufficient four-strand hamstring autograft diameter in anterior cruciate ligament reconstruction: A systematic review

PURPOSE

To evaluate the utility of semitendinosus tendon (ST) and gracilis tendon (GT) cross-sectional area (CSA) on magnetic resonance imaging (MRI) and anthropometric characteristics in preoperative estimation of graft diameter in patients undergoing anterior cruciate ligament reconstruction (ACLR) with four-strand hamstring autografts.

METHODS

Three databases were searched on 29 August 2023. The authors adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and R-AMSTAR (Revised Assessment of Multiple Systematic Review) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, anthropometric characteristics, imaging techniques, tendon CSA, correlation coefficients, sensitivities, specificities, regression models and cutoffs for predicting intraoperative graft diameters above 8 mm were recorded.

RESULTS

Forty-six studies comprising 4140 patients were included. Twelve of 19 (63.2%) studies reporting on ST + GT CSA found a moderate to very high correlation with intraoperative graft diameter. Five of 10 (50%) and one of seven (14.3%) studies reporting on ST CSA and GT CSA, respectively, found a moderate to high correlation with intraoperative graft diameter. Cutoffs of ST + GT CSA for predicting graft diameters above 8 mm ranged from 15.8 to 31.2 mm2. Nine of 35 (25.7%) studies that reported on height found a moderate to very high correlation with graft diameter. Seven of 33 (21.2%) studies reporting on weight found a moderate correlation with graft diameter.

CONCLUSION

Of the MRI parameters assessed, ST + GT CSA was the most reliable predictor of graft diameter. However, cutoffs, sensitivities, and specificities for predicting diameters above 8 mm were highly variable. Anthropometric characteristics in general were less predictive of graft diameter than MRI parameters. This information can be used by clinicians to predict patients at risk for ACLR failure due to insufficient graft size.

LEVEL OF EVIDENCE

Level IV.

Novel technique of predicting the dimensions of 5-stranded hamstring grafts for anterior cruciate ligament reconstruction: A descriptive study

Background

Prediction of hamstring tendon autografts is essential when planning a ligament reconstruction surgery. This is especially important in cases of multiple ligament reconstruction surgeries. This study was designed to predict the dimensions of 5-stranded hamstring grafts from anthropometric parameters in patients undergoing anterior cruciate ligament (ACL) reconstruction surgery.

Methods

172 patients undergoing ACL reconstruction with hamstring autografts were included in the study. Preoperative parameters included age, gender, height, weight, body mass index (BMI), thigh length, thigh circumference, and tibia length; intraoperative parameters included semitendinosus (ST) and gracilis (G) length and diameter, final 5-stranded graft length and diameter. Pre-operative data was correlated with intra-operative data using tests of significance.

Results

Height, tibia and thigh length were greater in males (p < 0.05) whereas BMI was greater in females (p < 0.05). G and ST length alongwith 5-stranded graft length and diameter were significantly greater in males (p < 0.05). The graft dimensions could be correlated with the pre-operative anthropometric parameters using specific equations. This was applicable to the lengths and diameters of ST, G and 5-stranded grafts. We also noted that an increase in age was associated with a reduction in graft dimensions except for the diameter of G graft in females and length of 5-stranded grafts in males.

Conclusion

5-stranded hamstring graft dimensions can be reliably predicted using anthropometric parameters and this eases surgical planning.

Correlation between anthropometric measurements and graft size in anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to investigate the correlation between anthropometric measurements and graft size in anterior cruciate ligament (ACL) reconstruction.

METHODS

A systematic search of Ovid MEDLINE, Embase, and Cochrane Library databases was conducted for observational studies published until March 2023 that reported the relationship between anthropometric data [height, weight, body mass index (BMI), age, gender, thigh length, and circumference] and ACL graft size. Correlation coefficients (COR) and their associated 95% confidence intervals were used as the primary effect size. This review was conducted in line with PRISMA guidelines.

RESULTS

A total of 42 observational studies involving 7110 patients were included, with a mean age of 29.8 years. Statistically significant, moderately positive correlations were found between graft size and height (COR: 0.49; 95% CI: 0.41-0.57; p-value: < 0.001), weight (COR: 0.38; 95% CI: 0.31-0.44; p-value: < 0.001), thigh circumference (COR: 0.40; 95% CI: 0.19-0.58; p-value: < 0.001), and thigh length (COR: 0.35; 95% CI: 0.18-0.50; p-value: < 0.001). However, age and gender were insignificantly correlated with graft size (p-value: NS). A subanalysis based on graft type showed a significant positive correlation between height and graft diameter, which was more significant in the peroneus tendon than in hamstring grafts (COR: 0.76 vs. 0.45; p-value: 0.020).

CONCLUSION

This study demonstrated a moderate positive correlation between anthropometric measurements (height, weight, thigh circumference, and length) and ACL graft size, along with a weak positive correlation with BMI. Age and gender showed no significant correlation. These findings support the predictability and selection of ACL graft size based on pre-operative patient anthropometric data.

LEVEL OF EVIDENCE

Level of Evidence: IV. PROSPERO registration number: CRD42023416044.

A Web-Based Prediction Tool to Improve Identification of Patients With Undersized Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction

BACKGROUND

An undersized hamstring tendon (HT) autograft is significantly associated with a higher graft failure rate in anterior cruciate ligament reconstruction (ACLR) surgery. The ability to accurately predict inadequate HT graft diameter is critical, as it could assist surgeons in making better graft choices and surgical plans.

PURPOSE

To develop a web-based prediction tool to better assess the size of HT autograft and to help clinicians accurately identify patients with potentially undersized HT grafts in order to make appropriate clinical decisions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 588 patients who received primary arthroscopic single-bundle ACLR surgery with gracilis tendon (GT) and semitendinosus tendon (ST) autograft were retrospectively reviewed. According to the size of 4-strand HT graft, patients were divided into diameter ≥8 mm and <8 mm groups. The least absolute shrinkage and selection operator method and logistic regression were used to identify the independent factors associated with HT graft diameter and establish the models. The prediction performance of the model was evaluated by concordance index and calibration combined with external validation. The diagnostic performance of the prediction model was assessed by sensitivity, specificity, predictive values, and likelihood ratios. Decision curve analysis was used to evaluate the clinical utility of the model.

RESULTS

Among the numerous indicators, sex, weight, height, thigh length, and ST-GT diameter (measured on plane 1 of a magnetic resonance imaging scan) were identified to be highly correlated predictors that could provide satisfactory prediction performance in determining the HT graft diameter. Based on these predictors, a prediction model named the HTD model was developed with satisfactory discrimination (concordance index, 0.932) and calibration (mean absolute error, 0.039). When the probability calculated by the HTD model was >65%, the sensitivity and specificity of predicting 4-strand HT graft diameter ≥8 mm were 86.7% and 90.2%, respectively.

CONCLUSION

As a useful supplementary prediction tool, the HTD model could accurately predict the diameter of HT autograft during preoperative planning.

Anthropometry in predicting Semitendinosus and Gracilis graft diameter for arthroscopic ACL reconstruction among the Bengali population

Semitendinosus and Gracilis autografts are commonly used for anterior cruciate ligament (ACL) reconstruction. However, its main drawback is individual variation in the tendon diameter. This study aimed to evaluate the usefulness of the anthropometric measurements for the prediction of Semitendinosus and Gracilis combined (quadrupled) strands graft diameter in arthroscopic ACL reconstruction among the Bengali population. Sixty consecutive patients who underwent ACL reconstruction between July 2019 to June 2020 were observed in this cross-sectional study. In all cases, the doubled (2 strands) Gracilis and Semitendinosus tendons were combined to get the final quadrupled (combined 4 strands) graft for use. Anthropometries such as body mass index (BMI), body weight, and height were recorded preoperatively and quadrupled combined tendon diameter was measured at the operating theater. The relationship between these parameters was statistically determined using the Pearson correlation coefficient, and scatter diagrams were plotted. Among the study subjects, most (54) were male, and the mean age of all subjects was 24 ± 6.92 years. The average graft diameter was 7.20 ± 0.76 mm. Correlations between the mean graft diameter with BMI (r = 0.018, and P = .891), body height (r = 0.011 and P = .933), and weight (r = 0.028 and P = .832) were not significant. Scatter diagrams also showed that the variables were not correlated. Anthropometries like BMI, body weight, or body height cannot be used in predicting Semitendinosus and Gracilis tendon graft diameter for arthroscopic ACL reconstruction among the Bengali population.

A fast, easy and reliable method for hamstrings graft size prediction in anterior cruciate ligament reconstruction

PURPOSE

The aim of this study is to describe and validate a simple and reliable method to pre-operatively predict the size of the ACL graft in the double strand technique with autologous semitendinosus-gracilis tendons on the same MRI used for ACL rupture diagnosis.

METHODS

The study included 92 patients, with a median age of 31 years (IQR 26-41 years), 73/92 (79%) of whom were males. All patients that underwent an ACL reconstruction with doubled ST + GT between 2017 and 2022 were counted in the study.

RESULTS

Overall, the median predicted graft diameter from MR imaging was similar to the actual graft diameter with no significant differences (n.s.). Regarding the comparison between predicted and actual graft size, concordance was 78/92 (85%, 95% CI 76-91%), with κ = 0.797 which corresponds to a level of agreement defined as "Strong". Tendon sizes calculated on pre-operative MRI were evaluated both with intra-observer and inter-observer reliability demonstrating a statistically reproducible method. The predicted graft was then compared to the reported one with a statistically significant reliability found.

CONCLUSION

This study can help the surgeons to perform a fast pre-operative planning of an ACL reconstruction for graft selection. If the planned graft with ST and GT is smaller than 8 mm, the clinician can decide to switch to a different type of graft or plan a different graft preparing technique and, therefore, reduce the risk of post-operative ligament re-rupture. The method proposed is reliable and reproducible. The major strength of the planning technique proposed is that it relies on data that are already available for the clinician before surgery, without the need of further analysis.

LEVEL OF EVIDENCE

IV.

Thigh Length as the Most Consistent Anthropometric Parameter in Predicting the Size of Hamstring Tendon Autografts in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Cross-Sectional Study

Background

Individual variability in the length and thickness of hamstring tendon autografts is a serious drawback in using these tendons for anterior cruciate ligament reconstruction (ACLR). In this study, we aimed to determine the correlation between the anthropometric parameters and the size of hamstring tendon autografts.

Methods

In a cross-sectional study, 52 male ACLR candidates were included. The length of semitendinosus and gracilis tendons and the diameter of single, doubled, and quadrupled tendons were measured. A graft sizing block device with an incremental size change of 0.5 mm (range 4.5-12) was used to measure the tendon graft diameter. The evaluated anthropometric parameters included age, gender, height, weight, BMI, thigh length and diameter, calf length, thigh-to-calf ratio, wrist diameter, and ankle diameter. A Pearson's or Spearman's correlation coefficient test was used for evaluating the correlation of anthropometric factors with graft characteristics.

Results

The mean age of the patients was 27.1 ± 6.4 years. The semitendinosus length was significantly correlated with the patient's height (r = 0.373, P = 0.007), thigh length (r = 0.364, P = 0.009), and calf length (r = 0.340, P = 0.015). The gracilis length was significantly correlated with thigh length (r = 0.278, P = 0.049). The mean quadruple diameter was 8.56 ± 1.15 mm (range 6.5-11). The quadruple diameter was significantly correlated with the thigh length (r = 0.283, P = 0.044). No other significant correlation was found between the tendons' size and evaluated anthropometric parameters.

Conclusion

Thigh length was correlated with the semitendinosus length, gracilis length, and quadruple diameter. Therefore, it could be regarded as the most consistent and promising anthropometric factor in the prediction of hamstring autograft size.

Application of human data to predict hamstring tendon autograft diameter in Zhuang population

BACKGROUND

To explore the value of human data from the Zhuang population via predicting the diameter of the hamstring tendon autograft in anterior cruciate ligament (ACL) reconstruction and determining the feasibility of preoperative ultrasound for prediction.

METHODS

In total, 24 Zhuang patients who underwent ACL reconstruction with a 4-strand semitendinosus and gracilis tendon autograft (4 S-STG) were enrolled in this study. Before the operation, the affected semitendinosus tendon (ST) was examined by ultrasonography, and its length, diameter, cross-sectional area, and circumference were measured. The patients' basic information and body data, ie, height, weight, body mass index, lower limb length injured, and thigh circumference injured, were recorded. Their ST and gracilis tendon lengths and diameters and 4 S-STG diameter were measured during the operation. A correlation analysis was conducted between the ultrasound measurement results and human data and intraoperative tendon measurements.

RESULTS

The ST diameter measured by ultrasound was correlated with the ST length and ST diameter measured during operation, and the ST circumference measured by ultrasound was correlated with the ST diameter measured during operation. The patients' body weight can be used to distinguish a 4 S-STG diameter of ≥8 mm (P < .01, mean difference = 11.59). The area under the receiver operating characteristic curve of body weight was 0.829. The final graft diameter ≥8 mm could be predicted with a body weight of 61.5 kg as the cutoff point; the sensitivity and specificity were 72.2% and 83.3%, respectively.

CONCLUSION

In Zhuang patients undergoing ACL reconstruction with 4 S-STG, body weight more accurately predicted graft diameter than preoperative semitendinosus diameter.

Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis

BACKGROUND

Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter.

PURPOSE

To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively.

RESULTS

Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups.

CONCLUSION

At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.

Changes in the Cross-Sectional Profile of Treated Anterior Cruciate Ligament Within 2 Years After Surgery

Background:

The cross-sectional area (CSA) of the anterior cruciate ligament (ACL) and reconstructed graft has direct implications on its strength and knee function. Little is known regarding how the CSA changes along the ligament length and how those changes vary between treated and native ligaments over time.

Hypothesis:

It was hypothesized that (1) the CSA of reconstructed ACLs and restored ACLs via bridge-enhanced ACL restoration (BEAR) is heterogeneous along the length. (2) Differences in CSA between treated and native ACLs decrease over time. (3) CSA of the surgically treated ACLs is correlated significantly with body size (ie, height, weight, body mass index) and knee size (ie, bicondylar and notch width).

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Magnetic resonance imaging scans of treated and contralateral knees of 98 patients (n = 33 ACL reconstruction, 65 BEAR) at 6, 12, and 24 months post-operation were used to measure the ligament CSA at 1% increments along the ACL length (tibial insertion, 0%; femoral insertion, 100%). Statistical parametric mapping was used to evaluate the differences in CSA between 6 and 24 months. Correlations between body and knee size and treated ligament CSA along its length were also assessed.

Results:

Hamstring autografts had larger CSAs than native ACLs at all time points (P < .001), with region of difference decreasing from proximal 95% of length (6 months) to proximal 77% of length (24 months). Restored ACLs had larger CSAs than native ACLs at 6 and 12 months, with larger than native CSA only along a small midsubstance region at 24 months (P < .001). Graft CSA was correlated significantly with weight (6 and 12 months), bicondylar width (all time points), and notch width (24 months). Restored ACL CSA was significantly correlated with bicondylar width (6 months) and notch width (6 and 12 months).

Conclusion:

Surgically treated ACLs remodel continuously within the first 2 years after surgery, leading to ligaments/grafts with heterogeneous CSAs along the length, similar to the native ACL. While reconstructed ACLs remained significantly larger, the restored ACL had a CSA profile comparable with that of the contralateral native ACL. In addition to size and morphology differences, there were fundamental differences in factors contributing to CSA profile between the ACL reconstruction and BEAR procedures.

Registration:

NCT 02664545 (ClinicalTrials.gov identifier).

The efficacy and medium-term outcomes of ligament advanced reinforcement system compared with auto-grafts in anterior cruciate ligament reconstruction: At least 2 years follow-up

Background: Graft choice is an important step in the pre-operative plan of anterior cruciate ligament reconstruction (ACLR). The four-strand hamstring tendon (4SHT) is the most widely used auto-graft, while the Ligament Advanced Reinforcement System (LARS) is the newest typical biomaterial for ACLR. The physical activity level (PAL) before injury can affect the efficacy and outcomes of ACLR. This study aims to compare the efficacy and functional outcomes between ACLR using LARS and 4SHT in patients different PALs.

Methods: This was a prospective paired case-control study. ACL rupture patients included from 1 January 2017 to 31 December 2019 were subsequently divided into the high and plain PAL groups, according to their baseline PAL before injury. Clinical assessments included: Lachman test, pivot shift test, ligament laxity, Lysholm and International Knee Documentation Committee (IKDC) scores, and rate of returning to sports. The minimum follow-up was 2 years (y).

Results: A total of 58 patients had accomplished the 2 y follow-up (missing rate: 6.5%). In the high PAL group (n = 22), the positive rate of A–P laxity of the LARS subgroup was lower than the 4SHG subgroup (p = 0.138), while the Lysholm score (p = 0.002), IKDC score (p = 0.043), and rate of returning to sports (p = 0.010) of the LARS were higher than the 4SHG at 1 year follow-up; the positive rates of A–P laxity (p = 0.009) and pivot test (p = 0.027) were lower in the LARS than the 4SHG at 2 y follow-up. In the plain PAL group (n = 36), the positive rate of A–P laxity in the LARS subgroup was lower than the 4SHG at 1 year follow-up (p = 0.017); the positive rates of A–P laxity (p = 0.001), Lachman (p = 0.034), and pivot tests (p = 0.034) in the LARS were also lower than the 4SHG at 2 y follow-up, but the IKDC score (p = 0.038) and rate of returning to sports (p = 0.019) in the 4SHG were higher than the LARS.

Conclusion: In patients with high PAL, LARS can acquire better knee stability, sooner functional recovery, and returning to sports than 4SHG, while in patients without high PAL, 4SHG acquires better functional outcomes and a higher rate of returning to sports.

Correlation between height and semitendinosus tendon length, prediction of minimum semitendinosus tendon length based on height-an easy and accurate method

PURPOSE

To find out an easy method to predict tendon length on the basis of patient height.

METHODS

A prospective study which included 256 patients. All patients underwent ligament reconstruction using semitendinosus graft. Pre-operatively age, gender, height and weight were noted. Harvested semitendinosus graft's length and diameter was measured.

RESULTS

Both the patient height as well as weight correlated with tendon diameter and tendon length (p-value < 0.05). A simple equation was also derived to pre-operatively predict tendon length.

CONCLUSION

To predict graft size, surgeon should consider anthropometric variables. If we divide height of the patient with six, we get the approximate length of the tendon and by subtracting three from the obtained value we are more than 90% sure that ST would not be shorter than this.

LEVEL OF EVIDENCE

level 4.

The Efficacy and Outcome of a Two-Staged Operation for Irreducible Knee Dislocation: A Prospective Short-Term Follow-Up

Background: Irreducible knee dislocation (IKD) is a very rare but serious type of knee dislocation; it can lead to soft tissue necrosis due to incarceration of the medial structures and faces great difficulty in the postoperative rehabilitation, too. IKD needs careful pre-operative planning. There is no universal agreement about the appropriate surgical strategy for IKD. The purpose of this study was to investigate the clinical efficacy, safety, and outcome of the two-staged operation in treatment of IKD. Methods: IKD patients were included from June 1, 2016 to May 31, 2020. In the stage-1 surgery, acute reduction and extra-articular structure repair were performed. Following an intermediate rehabilitation, delayed cruciate ligament reconstructions were performed in stage-2. Physical examination, CT, MRI, and X-ray were performed during the pre-operative period. Knee function, joint stability, ligament laxity, knee range of motion (ROM), and alignment were accessed at follow-ups. The minimum and maximum follow-up times were 0.5 years and 1 year, respectively. Results: In total, 17 IKD patients were included. There were three subjects (17.65%) missing at the 1 year follow-up and the average follow-up was 11.18 ± 2.53 months. After stage-1, normal alignment and superior valgus/varus stability were restored in most subjects; however, a notable anterior-posterior instability still existed in most patients. The intermediate rehabilitation processed smoothly (6.94 ± 1.20 weeks), and all patients achieved knee ROM of 0-120° finally. At 0.5 years and 1 year follow-up after stage-2, all subjects had achieved normal knee stability, ROM, and satisfying joint function. No infection or DVT was observed. Conclusions: The two-staged operation for IKD has superior efficacy on knee stability and function, and it can facilitate the rehabilitation and achieve satisfactory short-term outcome.

"Y" Graft Double Bundle Anterior Cruciate Ligament Reconstruction

Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been a standard procedure. However, residual rotary instability in approximately 20% of the cases (irrespective of the graft choice and the surgical technique) forces the surgeon to improve the biomechanical quality of the reconstruction. In parallel, adjustable suspensory fixation (ASF) devices have arisen. Biomechanics has defined (both anatomical and functional) the anteromedial (AM) and posterolateral (PL) bundles that work synergistically. In the unsymmetrical "anatomic" SB ACL reconstruction, the distribution of the ACL graft fibers (for AM or PL behavior) is not under the control of the surgeon. Furthermore, different sizes of the original footprints (depending on height) suggest the need to customize the graft footprint. This customization is only possible if distances are measured during surgical procedures. We present an inside-out technique for DB ACL reconstruction ("all-inside" also possible). Semitendinosus is folded to obtain a Y-shaped trifurcate configuration graft, distributing their bundles in two different areas. Used as measuring instruments, we used the "offset" guides as measuring instruments, allowing the surgeon to know the distance between the centers of the AM and PL tunnels. It may be carried out by means of common "offset" guides and any marketed ASF devices, while generating customized footprints.

CLASSIFICATION

I: knee; II: ACL.

Quadrupled Hamstring Graft Diameter Adequacy in Anterior Cruciate Ligament Reconstruction Using Patient Anthropometry: A Prospective Cohort Study in Indian Males

Background and aim The diameter of the graft used for the reconstruction of the anterior cruciate ligament (ACL) is an important determinant for the overall strength and future outcome of the operative procedure. Preoperative prediction of quadrupled hamstrings autograft (QHAG) diameter can prove to be of help in forecasting the need for augmentation or alternative grafts like quadriceps, bone-patellar tendon-bone autograft, and synthetic grafts. The relationship between the preoperatively assessed anthropometric parameters and the obtained quadrupled hamstrings graft diameter has not been extensively studied, especially in the population of Indian origin. This study aimed at investigating whether a correlation exists between the measured anthropometric parameters like age, weight, height, thigh circumference, and body mass index (BMI) and the intraoperatively obtained diameter of hamstring graft for ACL reconstruction in the study population of Indian male subjects. Study design A prospective cohort study conducted in a tertiary care center and teaching hospital in a district in central Uttar Pradesh, India. Methods The preoperative anthropometric data (age, height, weight, BMI, and thigh circumference of the injured side) of 73 Indian male subjects undergoing primary ACL reconstructive surgeries between May 2018 and August 2020 were prospectively collected, and their respective intraoperative QHAG diameters measured and recorded. Pearson's correlation test was employed to determine the correlation between the preoperative demographic and anthropometric data and the obtained corresponding graft diameters. Simple linear regression was performed to obtain the graphical plots and determine the relationship between the dependent and independent variables. Of these, the variables showing significant association were subjected to stepwise linear regression to identify and exclude the confounder(s) and obtain the predicted equation. Results The study comprised 73 male participants. The study participants' mean age was found to be 33.7 years, mean height was 173.1 cm, mean weight was 71.2 kg, mean BMI was 23.7 kg/m², mean thigh circumference was 50.4 cm, and the obtained mean graft diameter was 8.0 mm. A strongly positive correlation was observed between height and the graft diameter (r=0.940, P=0.000) and thigh circumference and the graft diameter (r=0.769, P=0.000). In contrast, weight showed a moderately positive correlation with the graft diameter (r=0.514, P=0.000). A very weakly positive correlation was observed between the BMI of the subjects and the obtained graft diameters (r=0.236, P=0.045). However, no correlation was observed between the age and the final graft diameters (r=0.140, P=0.238). Subsequent linear regression analysis indicates that only height (R²=0.883, P=0.000; strong) and the thigh circumference (R²=0.591, P=0.000; moderate) share a significant predictive value for the obtained QHAG. Both height and thigh circumference together were good predictors for graft diameter as determined by multiple regression (F (2,70)=272.372, P<0.001), with an R² of 0.886. Conclusion Certain anthropometric parameters depict a positive correlation with the QHAG diameter and can assist in preoperative planning, predicting the possible harvested graft diameter and the need for alternative grafts or augmentation during ACL reconstructive surgeries.

Effect of Leg Dominance on Medium- to Long-Term Functional Outcomes, Quality of Life, and Revision Rates After Isolated ACL Reconstruction

Background:

The effect of leg dominance on short-term functional outcomes and return to sports after arthroscopic anterior cruciate ligament reconstruction (ACLR) has been evaluated. However, postoperative medium- to long-term recovery and revision rates are not well known.

Purpose:

To investigate whether leg dominance affects medium- to long-term clinical and functional scores and revision rates after ACLR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in this study were 235 patients (205 male and 30 female) who underwent isolated arthroscopic ACLR. Patients were divided according to the leg dominance status of their injured limb into 2 groups: dominant leg injured (120 patients) and nondominant leg injured (115 patients). Preoperative and postoperative functional outcomes and health-related quality of life (HRQoL) were evaluated using the visual analog scale for pain, Tegner activity scale, Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, 36-Item Short Form Health Survey (SF-36), and overall patient satisfaction. Moreover, the revision rates of the 2 groups were compared according to leg dominance, patient characteristics, and operative features.

Results:

The mean follow-up period was 8.0 ± 2.3 years (range, 5-13 years). A significant preoperative to postoperative improvement in range of motion and functional scores was noticed in both groups (P < .001 for all). However, the improvement was significantly higher in the dominant leg group for the Tegner (P = .001), Lysholm (P = .006), and IKDC (P < .001) scores as well as for the SF-36 domain scores for general health (P = .009), social role (P = .048), and emotional role (P = .032). Also, patient satisfaction was significantly higher in the dominant leg group (P = .007). The dominant leg group was associated with a lower revision rate compared with the nondominant leg group (5.8% vs 15.7%, respectively; P = .015).

Conclusion:

High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. However, leg dominance had a significant effect on postoperative medium- to long-term functional outcomes, HRQoL, and revision rates.

Determinants of regeneration and strength of hamstrings after anterior cruciate ligament reconstruction-fate of hamstring tendon

BACKGROUND AND AIM

Arthroscopic reconstruction of anterior cruciate ligament (ACL) surgical procedure using hamstring autograft is the most common surgery performed in the arena of sports medicine and arthroscopy. Most studies in literature are ambiguous regarding the fate of hamstrings based on function, regenerative potential, and cross-sectional area (CSA). The aim of this research study is analysis of the fate of hamstring tendons (both semitendinosus and gracilis) during the time course for determinants of regeneration and strength.

METHODS

Fifty patients who were operated for unilateral isolated ACL reconstruction from July 2015 to June 2018 were evaluated for the fate of harvested hamstring tendons which included the following: regeneration, cross-sectional area (CSA), strength, and insertion of regenerated hamstrings by isometric torque and isokinetic strength. MRI of knee was performed for both knees concerning the semitendinosus (ST), gracilis (G), Sartorius, biceps femoris, and medial head of gastrocnemius.

RESULTS

Eighty-four percent men and 16% women within a mean patient age of 34 ± 4.12 years were evaluated and all 50 (100%) patients demonstrated hamstring regeneration by the MRI measurements at six months and at one year post-ACL reconstruction. The torque of isometric knee flexion measured in 60° was found to be remarkably lower in the ACL-reconstructed lower extremity compared to that of the contralateral limb (87.13 ± 20.18% of BW), at 90° (49.17 ± 15.09% BW), and at 105° (43.91 ± 13.17% BW), respectively (p < 0.01). However, at 30° flexion and 45° flexion, the difference was insignificant (116.48 ± 21.07% BW for 30° and 100.16 ± 25.12% BW for 45°).

CONCLUSIONS

It was found that the properties of musculotendinous units of ST and G were significantly transformed after their harvesting for ACL reconstruction and these weaknesses contribute to the flexion deficit of knee in the deeper range of flexion in the operated limb. Therefore, approaches facilitating tendon regeneration and preservation must be warranted.

Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review

IMPORTANCE

Graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of interest among orthopaedic surgeons because no ideal graft has yet been found. Peroneus longus tendon (PLT) has emerged as an alternative autograft for reconstruction in kneeling populations and in simultaneous anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries.

OBJECTIVE

To evaluate the current evidence on the outcome of primary ACLR with PLT autograft in adults and donor ankle morbidity, in addition to determining the average PLT graft dimensions from published studies.

EVIDENCE REVIEW

Two independent reviewers searched PubMed, CENTRAL, EMBASE, Scopus and Virtual Health Library databases using the terms "anterior cruciate ligament," "peroneus longus" and "fibularis longus" alone and in combination with Boolean operators AND/OR. Studies evaluating clinical and stability outcomes, graft-donor ankle morbidity and graft dimensions of PLT in ACLR were included. Methodological quality was assessed using the Modified Coleman Methodology Score (mCMS). A narrative analysis is presented using frequency-weighted means wherever feasible. Publication bias was assessed using the ROBIS tool.

FINDINGS

Twelve articles with intermediate-level methodological quality were included. Eight studies assessing the clinical and stability outcomes of reconstruction with PLT showed satisfactory outcomes, similar to those of hamstring tendons (HT). No studies assessed anterior knee pain as an outcome. Six studies evaluated the graft-donor ankle morbidity using general functional foot and ankle scores and non-validated tools, showing favourable outcomes. Nine studies assessed PLT graft diameter, revealing grafts consistently larger than 7 mm among the different preparation techniques, which is comparable with reports of HT grafts.

CONCLUSIONS AND RELEVANCE

The clinical and stability outcomes of ACLR with different PLT autograft preparation techniques are comparable with those of HT during short-term follow-up; however, there is insufficient evidence to support its use in the populations that motivated its implementation. Thus, stronger evidence obtained with the use of validated tools reporting negligible donor-graft ankle morbidity after PLT harvesting is required prior to recommending its routine use, despite the consistency of its dimensions.

LEVEL OF EVIDENCE

Level III.

Comparison of semitendinosus tendon length and diameter in sports and non-sports group for ACL reconstruction

Different anthropometric parameters such as weight, height, body mass index, thigh circumference, and thigh length have been extensively studied and their correlation assessed with hamstring graft length and diameter. This study is to analyse the difference of semitendinosus graft characteristics with sports activity of the patient.

METHODS

110 patients undergoing any ligament reconstruction with semitendinosus were included, 55 in sports and 55 in non-sports group. Height, weight, BMI, sports activity were noted pre-operatively. Semitendinosus harvested and graft length and diameter measured.

RESULTS

98 patients completed the study. The mean length of the harvested semitendinosus tendons was 28.45 ± 2.54 cm in non-sports group and 28.06 ± 4.18 cm in sports group. The mean diameter of semitendinosus was 6.29 ± 0.61 mm in non-sports group and 6.35 ± 0.6 mm in sports group. Positive correlation was found between height and graft length. No statistically significant difference between tendon length (p = 0.994) and diameter (p = 0.549) of sports and non-sports group was found.

CONCLUSION

Patient height should be considered for preoperative prediction of tendon length and thickness without any difference in sports or non-sports group. A taller patient has a longer and thicker graft.