0
Surgical Techniques   |    
Anterior Cruciate Ligament Reconstruction with a Four-Strand Hamstring Tendon Autograft
Riley J. WilliamsIII, MD1; Jon Hyman, MD2; Frank Petrigliano, MD3; Tamara Rozental, MD4; Thomas L. Wickiewicz, MD1
1 The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for R.J. Williams III: williamsr@hss.edu
2 5671 Peachtree-Dunwoody N.E., Suite 700, Atlanta, GA 30342
3 Department of Orthopaedic Surgery, University of California at Los Angeles Medical Center, 10833 Le Conte Avenue, Los Angeles, CA 90095
4 University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA 19104
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Institute for Sports Medicine Research, New York, NY. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
The line drawings in this article are the work of Jennifer Fairman (jfairman@fairmanstudios.com).
Investigation performed by the Sports Medicine and Shoulder Service at The Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 225-232, February 2004

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Mar 01;87(1 suppl 1):51-66. doi: 10.2106/JBJS.D.02805
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

BACKGROUND:

In this study, we analyzed the clinical outcomes at a minimum of two years following reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented with a symptomatic torn anterior cruciate ligament.

METHODS:

One hundred and twenty-two consecutive patients who had an isolated, symptomatic anterior tibial subluxation associated with rupture of the anterior cruciate ligament were treated with reconstruction of the anterior cruciate ligament with a four-strand autologous semitendinosus-gracilis tendon graft. One surgeon performed all of the operations. Prior to surgery and at the follow-up examination, physical findings and functional scores were recorded and knee radiographs were analyzed. Following surgery, a six-month rehabilitation regimen was implemented.

RESULTS:

Eighty-five patients (70%) were available for follow-up, which included physical examination, scoring of function, KT-1000 arthrometric testing, and radiographs, at a mean of twenty-eight months. Seventy-six (89%) of the patients had negative Lachman and pivot shift tests. The mean Lysholm score improved from 55 points preoperatively to 91 points at the time of follow-up (p < 0.01). The mean Tegner score improved from 5 to 6 points (p < 0.01). Sixty-five patients had <3 mm of knee translation on arthrometric testing, but six patients with marked laxity were not tested. Three patients (4%) had a positive pivot shift test but had no history of additional trauma to the knee. Six patients (7%) had a traumatic rupture of the graft, occurring at a mean of 10.7 months postoperatively. Assessment of the follow-up radiographs demonstrated no evidence of progressive degenerative change compared with the appearance on the preoperative radiographs. However, tunnel expansion was noted in all patients. The tibial tunnel expanded a mean of 17% (range, 0% to 32%), and the femoral tunnel expanded a mean of 29% (range, 0% to 40%).

CONCLUSIONS:

Reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft eliminated anterior tibial subluxation in 89% of patients who were examined at a minimum of two years postoperatively. The overall rate of failure was 11%. The functional knee scores were significantly increased at the time of follow-up, but these results did not correlate with the results of knee arthrometric testing.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Nikolaos V. Bardakos, MD
    Posted on May 04, 2009
    Anterior Cruciate Ligament Reconstruction with a Four-Strand Hamstring Tendon Autograft
    The Royal Orthopaedic Hospital, Northfield, Birmingham, England

    EDITOR'S NOTE: The authors were invited to respond to the letter, but to date, have not done so.

    To the Editor:

    I read with great interest the paper by Williams,III, et al., in which the authors present the endoscopic surgical technique of anterior cruciate ligament reconstruction using the Endobutton CL (Smith & Nephew, Inc., Endoscopy Division, Andover, Massachusetts) for femoral fixation of the four-strand hamstring tendon autograft (1). I wish to comment on aspects of the technique of drilling the femoral tunnel with this fixation device.

    While the authors state that the primary femoral tunnel, “should measure between 25 and 30 mm in length”, they also state that the loop of the Endobutton CL should allow, “at least 25 mm of the hamstring graft within the femoral tunnel” (1). With the numbers provided, a turning radius of only 0-5 mm would be available for the Endobutton; this would make flipping it over the anterolateral femoral cortex very difficult, if not impossible, technically.

    Authors of previous reports on the use of the Endobutton have recommended overdrilling the femoral socket by 6 mm (2-4) or just short of the anterolateral femoral cortex (5,6). While the latter option has been reported to increase the risk for the Endobutton to deploy outside the vastus lateralis muscle (2), overdrilling by only 6 mm is just sufficient to allow it to deploy. Therefore, overdrilling by about 10 mm appears a reasonable compromise because it provides ample space for the Endobutton to flip while simultaneously limiting its potential excursion once outside the femur. Indeed, the manufacturer now recommends overdrilling of the femoral socket by 9-10 mm (7). It has also been my experience that this works well in clinical practice.

    Consequently, for a minimum of 25 mm of graft to rest in the femoral tunnel, reaming to 35-40 mm, rather than 25-30 mm, appears advantageous.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Williams RJ 3rd, Hyman J, Petrigliano F, Rozental T, Wickiewicz TL. Anterior cruciate ligament reconstruction with a four-strand hamstring tendon autograft. Surgical technique. J Bone Joint Surg Am. 2005;87 Suppl 1:51-66.

    2. Simonian PT, Behr CT, Stechschulte DJ Jr, Wickiewicz TL, Warren RF. Potential pitfall of the EndoButton. Arthroscopy. 1998;14:66-9.

    3. Karaoglu S, Halici M, Baktir A. An unidentified pitfall of Endobutton use: case report. Knee Surg Sports Traumatol Arthrosc. 2002;10:247-9.

    4. Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring tendon. Orthop Clin North Am. 2003;34:9-18.

    5. Barrett GR, Papendick L, Miller C. Endobutton button endoscopic fixation technique in anterior cruciate ligament reconstruction. Arthroscopy. 1995;11:340-3.

    6. Treme GP, Miller MD. Single-bundle ACL reconstruction technique: hamstring autograft. In: Fu FH, Cohen SB, editors. Current concepts in ACL reconstruction. Thorofare, NJ: SLACK Incorporated; 2008. p 201-212.

    7. Rosenberg TD. ACL reconstruction with the ACUFEX director drill guide and ENDOBUTTON CL fixation system. http://www.global.smith-nephew.com/us. Accessed May 1, 2009.

    Riley J. Williams III, M.D.
    Posted on June 13, 2005
    Dr. Williams, et al respond to Dr. Narvani, et al
    The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021

    My co-authors and I would like to thank Dr. Narvani for his astute observation of this error. He is correct in pointing out that the femoral tunnel during ACL reconstruction should be in the eleven o'clock position for left knees and in the one o'clock position for right knees.

    Riley J. Williams III, MD

    Freddie H. Fu
    Posted on April 26, 2005
    Femoral insertion site of the anterior cruciate ligament
    University of Pittsburgh School of Medicine, Department of Orthopaedic Surgery

    To The Editor:

    It was with great interest that I read the March 2005 JBJS Surgical Techniques Supplement. On the cover of that issue, there is a schematic drawing of a knee joint during ACL single-bundle reconstruction. This illustration also depicts the position of the tibial and the femoral bone tunnels (Figure 1).

    Since I have been performing anatomic ACL double-bundle reconstructions as my preferred technique for the past 18 months, I have learned a great deal about the anatomy of the tibial and femoral ACL insertion sites. In fact, the femoral insertion site of the ACL covers a broad area on the lateral femoral condyle. Below, is a picture of a cadaveric specimen that illustrates the broad insertion areas of the anteromedial (AM) and the posterolateral (PL) bundles of the ACL on the femoral side (Figure 2).

    In addition, I have observed that the position of the femoral insertion of the PL bundle changes throughout flexion and extension of the knee joint. Figure 3a (left, below) shows the femoral insertion sites of the AM and the PL bundle in the extended knee position, with the PL insertion distal to the AM insertion. However, arthroscopic ACL reconstruction procedures are usually performed in 90 degrees of knee flexion. Flexing the knee joint to 90 degrees changes the position of the femoral PL insertion site and brings it more to the front, as illustrated in Figure 3b(below,right).

    For that reason, the clock system is of limited value for the choice of the tunnel position since the insertion sites of the AM bundle and the PL bundle are not in the same coronal plane. I had not realized this phenomenon until I started performing anatomic ACL double-bundle reconstructions. I believe that this three-dimensional concept needs to be understood by knee surgeons who perform either ACL single-bundle or anatomic ACL double- bundle reconstructions.

    Sincerely,

    Freddie H. Fu, MD, DSc (Hon), DPs (Hon)

    Amir A Narvani
    Posted on April 09, 2005
    Anterior Cruciate Ligament Reconstruction with a Four Stranded Hamstring Tendon Autograft
    BSc, MB BS, MRCS, MSc (Sports Med)

    To The Editor:

    We would like to thank Williams, et al, for their very informative and clear “Surgical Technique” article titled “Anterior Cruciate Ligament Reconstruction with a Four-Stranded Hamstring Tendon Autograft” (2005; 87- A: S(1): 51-66). Do the authors really mean eleven o’clock position for the right knee and one o’clock position for the left knee instead of the published “one o’clock position for the right knee and eleven o’clock position for the left knee” for femoral tunnel placement (pages 59 & 61)?

    -Amir Ali Narvani, MRCS

    -Elefterios Tsirisdis, FRCS

    69A Frognal

    London NW3 6YA

    alinarvani@hotmail.com

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    04/16/2014
    Georgia - Choice Care Occupational Medicine & Orthopaedics
    04/23/2014
    Massachusetts - UMass Memorial Medical Center
    01/08/2014
    Pennsylvania - Penn State Milton S. Hershey Medical Center