Predictive Factors of Hamstring Tendon Regeneration and Functional Recovery After Harvesting: A Prospective Follow-up Study

Higher rates of anatomical insertion of medial hamstring tendon regeneration post-anterior cruciate ligament reconstruction with stump preservation graft harvesting technique: A prospective, randomised, double-blinded clinical trial with magnetic resonance imaging evaluation

OBJECTIVE(S)

The purpose of this study was to compare the regeneration of semitendinosus and gracilis tendons from two different graft harvesting techniques, which are the stump preservation and conventional graft harvesting techniques. We hypothesised that the stump preservation graft harvesting technique, which preserved the distal attachment of tendons at their insertion, would facilitate anatomical regeneration to the pes anserinus.

METHODS

This is a prospective, randomised, double-blinded study whereby thirty consecutive patients who underwent single bundle anterior cruciate ligament reconstruction with ipsilateral semitendinosus and gracilis autografts were recruited. The patients were randomly assigned to the stump preservation group (14 patients) or conventional group (16 patients). Magnetic resonance imaging (MRI) evaluation was performed preoperatively and at six months post-operatively.

RESULTS

At 6-month follow-up, MRI evaluations showed a higher percentage of insertion of regenerated semitendinosus and gracilis at the pes anserinus in the stump preservation group (75.0%) than that in the conventional group (68.8%). There was a significantly higher proximal shift of the musculotendinous junction of semitendinosus (5.70 ​cm versus 3.36 ​cm, p ​= ​0.029) and gracilis (5.28 ​cm versus 3.16 ​cm, p ​= ​0.045) in the conventional group post-operatively.

CONCLUSION

The stump preservation technique yields a higher percentage of anatomical insertion of regenerated tendons and a lesser amount of proximal shift of the musculotendinous junction.

LEVEL OF EVIDENCE

III - Prospective study with up to two negative criteria.

Enlightenment on Knee Flexors Strength Loss in Cases of Posterior Knee Pain After Anterior Cruciate Ligament Reconstruction

CONTEXT

The persistence and the recurrence of posterior medial knee pain (PKP) after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon graft are often overlooked during rehabilitation.

DESIGN

Cross-sectional observational study.

METHODS

The study aimed (1) to evaluate the prevalence of these types of PKP before 4 months post-ACLR, (2) to measure their consequences on the knee flexors strength, and (3) to evaluate the role of the type of ACLR. From a cohort of patients operated on with hamstring tendon procedures, the persistent and the recurrent PKP were sought at 4 months post-ACLR. The evolution of isokinetic muscle strength recovery in PKP subjects was compared with those of nonpainful subjects. The functional deficit was measured at 6/7 months post-ACLR by a hop test.

RESULTS

Three hundred seventeen subjects (25.8 [6.0] y) were included. At 4 months post-ACLR, 2 populations were identified based on the recurrent onset of PKP (PKP+, n = 40) or the absence of knee pain (PKP-, n = 277). The prevalence of PKP was 8.3%. At the fourth month post-ACLR, the PKP+ group had a higher flexor strength deficit compared with the PKP- group (limb symmetry index at 60°/s: 67.2% [12.4%] vs 84.3% [12.6%]; P < .05). At 6/7 months, the loss of strength persisted (limb symmetry index at 60°/s: 82.3% [13.4%] vs 87.7% [12.8%]; P < .05). The hop test deficit was comparable, and no difference was shown according to the type of graft.

CONCLUSIONS

Persistent and recurrent PKP during the rehabilitation period were not uncommon and were associated with a worsening of flexors strength loss on the ACLR side.

Hamstring Anterior Cruciate Ligament Autograft Contributes to a Delayed Symptomatic Cyclops Lesion: A Case Report

Cyclops lesions are characterized as fibroid nodules with granulation tissue that looks similar to a cyclops eye during arthroscopy. These are rare postoperative complications following anterior cruciate ligament reconstruction (ACLR), presenting typically within six months of their reconstruction. This case report presents a 21-year-old male, three years following hamstring autograft ACLR, with a symptomatic cyclops lesion. Contrary to the reported literature, this delayed presentation showed a painful flexion contracture of the knee and intraoperative findings consistent with a cyclops lesion. The treatment consisted of surgical debridement and notchplasty with subsequent posterior medial and lateral meniscal horn repairs. This case report presents a lesson to indicate that cyclops lesions can occur in a delayed setting following ACLR and to show a technique for successful surgical management of the lesion.

Shape differences in the semitendinosus following tendon harvesting for anterior cruciate ligament reconstruction

Following hamstring autograft anterior cruciate ligament reconstruction (ACLR), muscle length, cross-sectional area, and volume are reduced. However, these discrete measures of morphology do not account for complex three-dimensional muscle shape. The primary aim of this study was to determine between-limb semitendinosus (ST) shape and regional morphology differences in young adults following tendon harvest for ACLR and to compare these differences with those in healthy controls. In this cross-sectional study, magnetic resonance imaging was performed on 18 individuals with unilateral ACLR and 18 healthy controls. Bilaterally, ST muscles were segmented, and shape differences assessed between limbs and compared between groups using Jaccard index (0-1) and Hausdorff distance (mm). Length (cm), peak cross-sectional area (cm² ), and volume (cm³ ) were measured for the entire muscle and proximal, middle, and distal regions, and compared between limbs and groups. Compared to healthy controls, the ACLR group had significantly (p < 0.001, Cohen's d = -2.33) lower bilateral ST shape similarity and shape deviation was significantly (p < 0.001, d = 2.12) greater. Shape deviation was greatest within the distal region of the ACLR (Hausdorff: 23.1 ± 8.68 mm). Compared to both the uninjured contralateral limb and healthy controls, deficits in peak cross-sectional area and volume in ACLR group were largest in proximal (p < 0.001, d = -2.52 to -1.28) and middle (p < 0.001, d = -1.81 to -1.04) regions of the ST. Overall, shape analysis provides unique insight into regional adaptations in ST morphology post-ACLR. Findings highlight morphological features in distal ST not identified by traditional discrete morphology measures. Clinical significance: Following ACLR, risk of a secondary knee or primary hamstring injury has been reported to be between 2-to-5 times greater compared to those without ACLR. Change in semitendinosus (ST) shape following ACLR may affect force transmission and distribution within the hamstrings and might contribute to persistent deficits in knee flexor and internal rotator strength.

The Muscle Strength of the Knee Joint after ACL Reconstruction Depends on the Number and Frequency of Supervised Physiotherapy Visits

The aim of this study in anterior cruciate ligament reconstruction (ACLR) patients was to assess the effect of six months of supervised physiotherapy with a higher number of visits (SPHNV) compared to supervised physiotherapy with a lower number of visits (SPLNV) on the maximal peak torque (PT) and isometric torque (IT) of values obtained for hamstring (H) and quadriceps (Q) muscles of the knee joints under isokinetic and isometric conditions. Hypothesis: SPHNV improves IT and PT more than SPLNV. Group I had ACLR with a higher number of visits (n = 20), Group II had ACLR with a lower number of visits (n = 20), and Group III served as the control (n = 20). In Groups I and II, IT values were measured for quadriceps and hamstring muscles of the knee joints in the 13th and 24th weeks and for PT in the 18th and 24th weeks after ACLR (60 and 180 °/s). In group III, the measurements were taken once. The isometric torque and isokinetic peak torque values were measured in N*m and they were normalized to body mass as relative IT (RIT) and relative PT (RPT) were expressed in N*m/kg. Results: In both ACLR groups, the RIT and RPT values obtained from the operated knee joints significantly increased in the 24 weeks following ACLR compared to the uninvolved side. Group II had significantly lower RIT and RPT values for quadriceps and hamstring muscles of the operated limbs compared with the uninvolved limbs (p = 0.008, p = 0.001). In group I, the larger number of visits positively correlated with the higher PT for quadriceps and hamstring muscles of the operated and uninvolved knees (from r = 0.506; p = 0.023 too r = 0.566; p = 0.009), respectively. Six months of SPHNV positively correlated with and improved the IT and PT values in patients after ACLR much more significantly than six months of SPLNV.

Preparation and biological characteristics of a bovine acellular tendon fiber material

Acellular tendon matrix is an ideal substitute for constructing tissue engineering ligaments, but using detergents causes damage to collagen and fibrin during the process of decellularization. In this study, fresh tendons were lyophilized and separated into fresh tendon fiber (FTF) bundles, and then the cellular components in FTF were removed to prepare acellular tendon fiber (ATF) without adding chemical detergent. H&E staining and DAPI fluorescence microscopy showed no nucleus and DNA residue. Compared with FTFs, the DNA content of ATFs was significantly lower without the collagen content change before and after decellularization. The microstructure of collagen fibrils in ATFs was intact under scanning electron microscopy (SEM), and the maximum tensile load and elastic modulus between FTFs and ATFs were not statistically different. The ATF bundles were cultured with SD rat tenocytes for 72 hr and cells attachment to fiber surfaces were observed under SEM. ATF bundles were then implanted into paraspinal muscles, and histological analysis showed fibroblast-like cells within the ATFs and was similar to the control group (fresh tendon autograft) in morphology. H&E staining showed that the number of lymphocytes and plasma cells in ATF was less than that in fresh tendon autograft. ATF bundles were twisted into linear fiber materials by hand, of which the maximum breaking strength was similar to silk with same diameter. These findings demonstrated that ATFs retain their original fibril structure and mechanical properties after decellularization by trypsin and pancreatic deoxyribonuclease without detergent. Lyophilized ATFs linear fiber material provides the possibility of preparing personalized ligament and other tissue engineering scaffolds.

Predictive Factors for Hamstring Autograft Diameter in Anterior Cruciate Ligament Reconstruction

Multiple studies found hamstring tendon (HT) autograft diameter to be a risk factor for anterior cruciate ligament (ACL) reconstruction failure. This study aimed to determine which preoperative measurements are associated with HT autograft diameter in ACL reconstruction by directly comparing patient characteristics and cross-sectional area (CSA) measurement of the semitendinosus and gracilis tendon on magnetic resonance imaging (MRI). Fifty-three patients with a primary ACL reconstruction with a four-stranded HT autograft were included in this study. Preoperatively we recorded length, weight, thigh circumference, gender, age, preinjury Tegner activity score, and CSA of the semitendinosus and gracilis tendon on MRI. Total CSA on MRI, weight, height, gender, and thigh circumference were all significantly correlated with HT autograft diameter (p < 0.05). A multiple linear regression model with CSA measurement of the HTs on MRI, weight, and height showed the most explained variance of HT autograft diameter (adjusted R ² = 44%). A regression equation was derived for an estimation of the expected intraoperative HT autograft diameter: 1.2508 + 0.0400 × total CSA (mm²) + 0.0100 × weight (kg) + 0.0296 × length (cm). The Bland and Altman analysis indicated a 95% limit of agreement of ± 1.14 mm and an error correlation of r = 0.47. Smaller CSA of the semitendinosus and gracilis tendon on MRI, shorter stature, lower weight, smaller thigh circumference, and female gender are associated with a smaller four-stranded HT autograft diameter in ACL reconstruction. Multiple linear regression analysis indicated that the combination of MRI CSA measurement, weight, and height is the strongest predictor.

Is there significant regeneration of the hamstring tendons after harvest for ACL reconstruction? A systematic review of literature

BACKGROUND

Regeneration potential of Hamstring tendons after harvest assumes significant clinical relevance as its use has become widespread today. Methods which best assess the regeneration, extent and type of regeneration, plus issues related to functional loss are important for the surgeon to know. This review looks at the literature to find answers to the above questions.

PURPOSE

To summarize the evidence in support of hamstring tendon regeneration, and the most appropriate modality for evaluation of regeneration. Additionally, to evaluate the regeneration in terms of complete or partial, extent and its impact on strength deficit and functional outcomes.

METHODS

We did a systematic review of literature through specified search engines and identified 30 of 285 studies to be relevant (19 prospective and 11 retrospective).

RESULTS

Evaluation of above data suggests tissue regeneration at harvest sites does occur (78.9% of semitendinosus and 42.7% of gracilis tendons), but this regeneration is variable. No established definition of regeneration exists; MRI is an adequate tool to identify regeneration, while biopsy is confirmative. USG is a cost-effective screening method and can document distal progress of regenerate. Semitendinosus and gracilis tendons regenerate at different rates and extents, and often fuse together, but there is no evidence to state that one regenerates better than the other. Proximal retraction of the muscle-tendon junction occurs, along with some atrophy, which affects function to a variable extent. Strength deficits may persist, but they may not convert to significant functional deficits.

CONCLUSION

There is variable hamstring regeneration after harvest, with poorly defined definition of "regeneration". Some changes in the muscle itself, abnormal distal insertion and absence of regeneration in some are documented, along with strength deficits. Although overall functional deficits have been reported to be minimal, a definite change in the anatomy of the medial hamstrings is a factor to be kept in consideration. More information is needed about the long-term consequences.

Use of Gracile and semi-tendinosus tendons (GRAST) for the reconstruction of irreparable rotator cuff tears

Background

Irreparable rotator cuff tears are common and difficult to treat. Techniques for “filling the loss of substance” require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula.

Methods

This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SS) and upper infraspinatus (IS) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy.

Results

The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases.

Conclusion

This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial “spacer” effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation.

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.

Tendon Regeneration After Partial-Thickness Peroneus Longus Tendon Harvesting: Magnetic Resonance Imaging Evaluation and In Vivo Animal Study

BACKGROUND

In recent years, the use of the anterior half of the peroneus longus tendon (AHPLT) as an autograft source for ligament reconstruction has gained popularity. However, no reports are available regarding tendon regeneration after harvesting of the AHPLT.

HYPOTHESIS

When half of the tendon is preserved during tendon harvesting, the quality of the regenerated tendon is better than that of the regenerated tendon after full-thickness harvesting.

STUDY DESIGN

Case series; Level of evidence, 4; controlled laboratory study.

METHODS

A total of 21 patients who underwent AHPLT harvesting for lower extremity ligament reconstruction participated in the magnetic resonance imaging (MRI) study to evaluate tendon regeneration 1 year after the harvesting. An in vivo animal study was performed to compare the quality of the regenerated tendon after partial-thickness and full-thickness tendon harvesting. A total of 30 adult female Sprague-Dawley rats were allocated to 2 groups-15 rats underwent partial-thickness Achilles tendon harvesting (partial-thickness harvesting [PTH] group), and 15 rats underwent full-thickness Achilles tendon harvesting (full-thickness harvesting [FTH] group). The quality of the regenerated tendons was compared 180 days after tendon harvesting.

RESULTS

All 21 patients showed regeneration of the peroneus longus tendon (PLT) (homogeneously dark on both T1- and T2-weighted sequences). The cross-sectional area of the regenerated tendon divided by that of the preoperative tendon was 92.6% and 84.5% at 4 cm and 9 cm proximal to the tip of the distal fibula, respectively. In the animal study, the mean histologic score was better for the PTH group compared with the FTH group (9.17 ± 1.35 vs 14.72 ± 0.74; P < .001). The ultimate strength and the stiffness of the regenerated Achilles tendon were significantly higher for the PTH group compared with the FTH group (35.5 ± 8.3 vs 22.4 ± 8.3 N, P = .004; and 31.6 ± 7.7 vs 23.5 ± 4.8 N/mm, P = .016).

CONCLUSION

The PLT was found to regenerate after partial-thickness harvesting on MRI. In the animal study, the quality of the regenerated tendon when half of the tendon was preserved during tendon harvesting was better than that after full-thickness tendon harvesting.

Anatomy of proximal attachment, course, and innervation of hamstring muscles: a pictorial essay

Hamstring injuries are very common in sports medicine. Knowing their anatomy, morphology, innervation, and function is important to provide a proper diagnosis, treatment as well as appropriate prevention strategies. In this pictorial essay, based on anatomical dissection, the detailed anatomy of muscle-tendon complex is reviewed, including their proximal attachment, muscle course, and innervation. To illustrate hamstrings' role in the rotational control of the tibia, the essay also includes the analysis of their biomechanical function.Level of evidence V (expert opinion based on laboratory study).

Percutaneous Lengthening of a Regenerated Semitendinosus Tendon for Medial Hamstring Snapping

In this surgical technique article, the authors describe a percutaneous tendon lengthening technique for surgical treatment of a regenerated semitendinosus tendon in snapping syndrome. Snapping syndromes are caused by 2 adjacent anatomic structures having a frictional catching, which may be associated with an audible pop. At the knee, they may have an intra- or extra-articular origin. It is imperative to understand the etiology of the snapping phenomenon to avoid unnecessary surgery.