Anterior Cruciate Ligament Reconstruction with Tibial Attachment Preserving Hamstring Graft without Implant on Tibial Side

Abstract

Background: Tibial attachment preserving hamstring graft could prevent potential problems of free graft in anterior cruciate ligament (ACL) reconstruction such as pull out before graft-tunnel healing or rupture before ligamentization. Different implants have been reportedly used for tibial side fixation with this technique. We investigated short-term outcome of ACL reconstruction (ACLR) with tibial attachment sparing hamstring graft without implant on the tibial side by outside in technique.

Materials and methods: Seventy nine consecutive cases of ACL tear having age of 25.7 ± 6.8 years were included after Institutional Board Approval. All subjects were male. The mean time interval from injury to surgery was of 7.5 ± 6.4 months. Hamstring tendons were harvested with open tendon stripper leaving the tibial insertion intact. The free ends of the tendons were whip stitched, quadrupled, and whip stitched again over the insertion site of hamstring with fiber wire (Arthrex). Single bundle ACLR was done by outside in technique and the femoral tunnel was created with cannulated reamer. The graft was pulled up to the external aperture of femoral tunnel and fixed with interference screw (Arthrex). The scoring was done by Lysholm, Tegner, and KT 1000 by independent observers. All cases were followed up for 2 years.

Results: The mean length of quadrupled graft attached to tibia was 127.65 ± 7.5 mm, and the mean width was 7.52 ± 0.78 mm. The mean preoperative Lysholm score of 47.15 ± 9.6, improved to 96.8 ± 2.4 at 1 year. All cases except two returned to the previous level of activity after ACLR. There was no significant difference statistically between preinjury (5.89 ± 0.68) and postoperative (5.87 ± 0.67) Tegner score. The anterior tibial translation (ATT) (KT 1000) improved from 11.44 ± 1.93 mm to 3.59 ± 0.89 mm. The ATT of operated knee returned to nearly the similar value as of the opposite knee (3.47 ± 1.16 mm). The Pivot shift test was negative in all cases. None had a failure of graft till final followup.

Conclusion: Attachment sparing hamstring graft without a tibial implant is a simple, cost-effective technique that provides a consistently satisfactory outcome.

Keywords: Anterior cruciate ligament; attachment preserving hamstring graft; autograft; knee; reconstruction; tibia.

Figure 1

Intraoperative photograph showing (a) Quadrupled hamstring graft whip stitched at tibial insertion (b) Prepared graft placed back in harvest bed

Figure 2

(a) Intraoperative fluoroscopy image showing that femoral guide in place with guide wire exiting at femoral footprint of anterior cruciate ligament. (b) Incision on femoral side for outside in technique (c) Intraoperative fluoroscopy image showing that guide wire through tibial footprint of anterior cruciate ligament

Figure 3

(a) Intraoperative fluoroscopy image showing that messenger wire from femoral tunnel and joint being passed through tibial tunnel (b) Loading of Ethibond (connected to graft) on messenger wire (c) Graft passage

Figure 4

Fluoroscopic view showing final intraarticular graft

Figure 5

Outside in interference fixation of the graft at femoral tunnel