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. 2020 Aug 26;8(8):2325967120946326.
doi: 10.1177/2325967120946326. eCollection 2020 Aug.

Failure Rates of 5-Strand and 6-Strand vs Quadrupled Hamstring Autograft ACL Reconstruction: A Comparative Study of 413 Patients With a Minimum 2-Year Follow-up

Ahmed Khalil Attia  1 , Hazem Nasef  1 , Kareem Hussein ElSweify  1 , Mohammed A Adam  1 , Faris AbuShaaban  2 , Kariyal Arun  2
Affiliations

Failure Rates of 5-Strand and 6-Strand vs Quadrupled Hamstring Autograft ACL Reconstruction: A Comparative Study of 413 Patients With a Minimum 2-Year Follow-up

Ahmed Khalil Attia et al. Orthop J Sports Med. .

Abstract

Background: Anterior cruciate ligament reconstruction (ACLR) with hamstring autograft has gained popularity. However, an unpredictably small graft diameter has been a drawback of this technique. Smaller graft diameter has been associated with increased risk of revision, and increasing the number of strands has been reported as a successful technique to increase the graft diameter.

Purpose: To compare failure rates of 5-strand (5HS) and 6-strand (6HS) hamstring autograft compared with conventional 4-strand (4HS) hamstring autograft. We describe the technique in detail, supplemented by photographs and illustrations, to provide a reproducible technique to avoid the variable and often insufficient 4HS graft diameter reported in the literature.

Study design: Cohort study; Level of evidence, 3.

Methods: We retrospectively reviewed prospectively collected data of all primary hamstring autograft ACLRs performed at our institution with a minimum 2-year follow-up and 8.0-mm graft diameter. A total of 413 consecutive knees met the study inclusion and exclusion criteria. The study population was divided into 5HS and 6HS groups as well as a 4HS control group. The primary outcome was failure of ACLR, defined as persistent or recurrent instability and/or revision ACLR.

Results: The analysis included 224, 156, and 33 knees in the 5HS, 6HS, and 4HS groups, respectively. The overall ACLR failure rate in this study was 11 cases (8%): 5 cases for 5HS, 3 cases for 6HS, and 3 cases for 4HS. No statistically significant differences were found among groups (P = .06). The mean graft diameter was 9 mm, and the mean follow-up was 44.27 months.

Conclusion: The 5HS and 6HS constructs have similar failure rates to the conventional 4HS construct of 8.0-mm diameter and are therefore safe and reliable to increase the diameter of relatively smaller hamstring autografts. We strongly recommend using this technique when the length of the tendons permits to avoid failures reportedly associated with inadequate graft size.

Keywords: 4-strand; 5-strand; 6-strand; ACL; hamstring autograft.

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Conflict of interest statement

The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. IRB approval was granted from Hamad Medical Corporation (protocol No. MRC-01-18-419).

Figures

Figure 1.
Figure 1.
Intraoperative clinical photographs showing the steps of the 5-strand hamstring graft preparation. (A) The whipstitch end of the harvested semi-T tendon is securely tied to the loop of the Endobutton. (B) The free end of the semi-T tendon is passed through the loop and the suture ends are tied to form the 3-strand semi-T graft part. (C) The gracilis is passed through the loop and folded on itself to from a double-strand graft. (D) The now 5 strand graft is secured by suturing all the 5 strands together. (E) The 5 strand graft is now ready to be measured.
Figure 2.
Figure 2.
Illustration of the 5-strand hamstring graft preparation. (A) The whipstitch end of the harvested semi-T tendon (white) is securely tied to the loop of the Endobutton. The needle of the proximal whipstitch is left in place. (B) The free end of the semi-T tendon is passed through the loop. (C) The suture ends are tied on either sides of the distal end to form a triple-strand configuration. (D) The final 5-strand configuration.
Figure 3.
Figure 3.
Details of excluded knees with quadrupled hamstring tendon autografts (4HS).
See this image and copyright information in PMC

References

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