Equation-based precise prediction of length of hamstring tendons and quadrupled graft diameter by various anthropometric variables for knee ligament reconstruction in Indian population

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.

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.

Predicting Quadruple Semitendinosus Graft Size for Anterior Cruciate Ligament Reconstruction by Patient Anthropometric Variables: A Cohort Study of 280 Cases

Introduction:

Pre-operative identification of patients with inadequate hamstring graft for anterior cruciate ligament reconstruction is still a subject of interest. The purpose of this study is to correlate dimension of a harvested dimensions graft with patient physical anthropometric variables.

Materials and methods:

This cohort study included 280 patients (male = 226, female = 54) scheduled for primary anterior cruciate ligament (ACL) reconstruction. Interrelationships between quadruple semitendinosus (ST) graft and anthropometric parameters (age, sex, height, weight, and BMI) were assessed using Pearson Correlation test and regression analysis. Difference among gender was analysed using Mann Whitney and t test. The observed graft diameter was also compared with the literature using Bland – Altman plot.

Results:

Mean age of cohort was 29 years (range, 17-50 years), mean height was 1.69m (range, 1.6-1.9m), mean weight was 75 kg (range, 50-116kg) and mean BMI was 26kg/m2 (range 16.65-40.40kg/m2). Mean quadruple length of harvested ST graft was 7cm (7.1±0.6 cm, range, 5.6-8.8cm) and mean diameter was 8mm (8.2±0.8mm, range, 6.5-10mm). Only height and weight were significantly correlated with graft length and diameter in both sex (p value <0.05). Female, compared to male, had significantly smaller (p<0.0001) and thinner graft (p<0.0001). There was a strong agreement between the literature and our observed graft diameter, but with an overestimated graft diameter in 18.5% of the cases.

Conclusion:

Among anthropometric parameter, only height and weight had moderate positive correlation with graft diameter. Males had longer and wider ST graft in contrast to age-matched female group.

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.

Relation of peroneus longus autograft dimensions with anthropometric parameters in anterior cruciate ligament reconstruction: Importance of the distal leg diameter

Objectives

This study aims to investigate the relationship between various anthropometric parameters and the diameter and length of the peroneus longus tendon (PLT) graft in the anterior cruciate ligament (ACL) reconstruction.

Patients and methods

A total of 52 patients (38 males, 14 females; mean age: 29.2±7.7 years; range, 17 to 51 years) who received PLT autograft for ACL reconstruction in our center between July 2018 and June 2020 were retrospectively analyzed. Demographic characteristics of the patients and leg length, and proximal and distal leg diameters were recorded before the operation. The PLT autograft diameter and length were measured during surgery.

Results

A statistically significant correlation was found between the graft diameter and length and weight, height, body mass index (BMI), leg length, and proximal and distal leg diameters (p<0.01). There was no statistically significant correlation between the graft diameter and length and age (p>0.05). Distal leg diameter had the highest correlation coefficient for the PLT autograft diameter (r=0.956), while the height had the highest correlation coefficient for the PLT autograft length (r=0.982).

Conclusion

Anthropometric parameters of height, weight, BMI, leg length, and proximal and distal leg diameters may be helpful for surgeons to predict the diameter and length of the PLT autograft before surgery. Distal leg diameter is a particularly important parameter in predicting PLT autograft diameter.

Correlation between anthropometric measurements and activity level on length and diameter of semitendinosus tendon autograft in knee ligament surgery: A prospective observational study

Introduction: Preoperative estimation of graft parameters can be useful while using hamstring grafts in knee ligament surgeries. Anthropometric parameters may be an easy way to predict the length and diameter of hamstring tendons. A prospective study was conducted to find the correlation between different anthropometric parameters and activity level of the patient on the length and diameter of the graft. Separate regression equations for males and females were also derived for easy prediction. Methods: Data were obtained from 95 patients who underwent arthroscopic anterior cruciate ligament reconstruction with autologous hamstring tendon graft. Variables studied were age, sex, height, weight, body mass index (BMI), thigh circumference, thigh length, Tegner activity level, diameter (double and quadruple) and length of semitendinosus tendon graft. Results: Height of the patient had strong correlation with graft length (r = 0.41, p < 0.001), double diameter (r = 0.29, p = 0.008) and quadruple diameter (r = 0.3, p = 0.006). Weight of the patients had strong positive correlation with graft length (r = 0.34, p = 0.002) and quadruple diameter (r = 0.34, p = 0.002). Thigh length was found to be positively correlating with graft length (r = 0.43, p < 0.001), double diameter (r = 0.29, p = 0.007) and quadruple diameter of graft (r = 0.34, p = 0.002). BMI and thigh circumference of the patients were not found to correlate with graft size. Male patients were found to have longer semitendinosus graft and larger double and quadruple diameter of the graft. There was no association between the Tegner activity scale and graft size. Regression equations between graft length and quadruple diameter and the anthropometric parameters are also derived. Conclusion: Height, weight and thigh length are useful anthropometric parameters in the prediction of hamstring tendon size. However, the patient’s Tegner activity level was not found to be associated with size of the hamstring tendon.

Preoperative Ultrasound Evaluation of the Semitendinosus Tendon for Anterior Cruciate Ligament Reconstruction

BACKGROUND

Adequate graft size and length are crucial factors that correlate with improved outcomes after anterior cruciate ligament reconstruction with a semitendinosus (ST) tendon autograft alone. Anthropometric parameters could be used as predictors of graft measurements but they have shown imprecise correlation in some patients.

PURPOSE

To evaluate the accuracy of ultrasound (US) for the preoperative evaluation of ST graft size and length.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A total of 40 patients were included in this study. Patient sex, age, anthropometric parameters, and preoperative US measurements were recorded. After the ST tendons were harvested, their lengths as well as the diameters of the 4-strand ST grafts were recorded. Correlations between patient US measurements were analyzed. Inadequate ST graft length was defined at <28 cm, and inadequate 4-strand ST graft diameter was defined at <8 mm.

RESULTS

The prevalence of patients with an ST graft length <28 cm was 47.5%, and the prevalence of patients with a 4-strand ST graft diameter <8 mm was 42.5%. US measurements had a strong, significant correlation with the ST graft length (P < .001) and a moderate correlation with the 4-strand ST graft diameter (P < .001). Absolute agreement between the preoperative US measurement of ST graft length and the intraoperative ST graft length showed good reliability (ICC_2,1 = 0.825). The cross-sectional area (CSA) of the ST tendon at the knee joint level by US showed a weak correlation (r = 0.207) with the 4-strand ST graft diameter (P = .200). A CSA of 16 mm² measured by US could be used to predict a 4-strand ST graft diameter ≥8 mm, with a sensitivity of 73.9% and specificity of 76.5%.

CONCLUSION

Preoperative US measurements of ST tendons had a strong correlation with intraoperative ST graft length and provided good sensitivity to detect a 4-strand ST graft diameter ≥8 mm. All other anthropometric parameters showed a weak to moderate correlation with ST graft length and size.

Predicting the graft diameter of the peroneus longus tendon for anterior cruciate ligament reconstruction

The aim of this study was to evaluate the correlation between various anthropometric parameters and the graft diameter of the peroneus longus tendon (PLT).We retrospectively analyzed the data of 156 patients who underwent anterior cruciate ligament reconstruction (ACLR) with the PLT graft at our institution. Anthropometric parameters, including height, weight, gender, age, duration of injury, and preinjury activity levels, were recorded. t tests, correlation coefficients (Pearson r), and a multiple linear regression analysis were used to evaluate the influence of these anthropometric variables on the diameter of the graft obtained.The mean PLT graft diameter was 8.3 mm, and 21 patients (13.5%) had a diameter less than 8 mm; 85 patients (54.5%) had a diameter between 8 and 9 mm, and 50 patients (32.0%) had a diameter greater than or equal to 9 mm. The correlation analysis showed that height (P < .001), weight (P < .001), and duration of injury (P = .012) were significantly related to graft diameter. On the basis of these 3 predictors, the following regression equation was obtained: Diameter = 2.28 + 0.028*height (cm) + 0.013*weight (kg) + 0.289*duration of injury (0 or 1). Patients who were short and shin were more likely to own smaller graft diameters (<8 mm), especially the one ruptured his or her anterior cruciate ligament (ACL) over 3 months.Height, weight, and duration of injury were associated with the diameter of PLT. They are important preoperative information for surgeon about the size of PLT and can be used for alternative graft source planning and patient counseling.Level of evidence: IV.