Original Articles
Biomechanical comparison of hamstring and patellar tendon graft anterior cruciate ligament reconstruction techniques: The impact of fixation level and fixation method under cyclic loading*

Presented in part at the 17th Annual Meeting of the Arthroscopy Association of North America, Orlando, Florida, April 30–May 3, 1998.
https://doi.org/10.1053/jars.2002.30609Get rights and content

Abstract

Purpose: To mechanically test different reconstruction techniques of the anterior cruciate ligament (ACL) under incremental cyclic loading and to evaluate the impact of the level and method of graft fixation on tensile properties of each technique. Type of Study: In vitro biomechanical study. Methods: Four hamstring and 1 patellar tendon reconstruction techniques were performed on 40 young to middle-aged human cadaveric knees (average age, 39 years). An anterior drawer with increasing loads of 20 N increments was applied at 30° of knee flexion. Anatomic, direct interference screw fixation was tested in 2 hamstring and in the patellar tendon groups. Nonanatomic (extracortical) graft anchorage was tested in the remaining 2 hamstring groups with indirect graft fixations on both sides and the combination of indirect tibial and direct femoral fixation. Structural properties were determined throughout the cyclic loading test. Results: The more anatomic reconstruction techniques provided significantly higher structural properties and smaller loss of fixation compared with nonanatomic, extracortical fixation, with indirect repair on both fixation sites resulting in the lowest structural properties. The tibial fixation site was the weakest link in all of the anatomic reconstructions. Patellar tendon fixation with attached bone blocks in both bone tunnels significantly improved construct stiffness and decreased graft slippage. Conclusions: The results of this study suggest that anatomic fixation should be preferred for anchorage of hamstring tendons and linkage materials should be avoided. Direct soft-tissue fixation with interference screws still allows considerable graft slippage, which can be limited by using a bone block or application of a backup or hybrid fixation, especially on the tibial fixation site.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 304–315

Section snippets

Methods

In this study, 40 human cadaveric knees were used that were an average age of 39 years (range, 18 to 56 years). Human semitendinosus, gracilis, and patellar tendons were harvested and immediately stored at −20°C. All knees and ligaments were thawed at room temperature 24 hours before use and kept moist with saline irrigation during preparation and mechanical testing. Knees with severe degenerative changes or trauma were excluded from the experiments. All soft-tissue structures except the ACL

Results

The data for 1 specimen in the HSTBio group were lost due to technical difficulties. Therefore, the number of specimens in this group was reduced to 7 while all the remaining groups consisted of 8 specimens. There was no statistical difference in age distribution between the groups.

The number of specimens in the HSTBio group decreased during the cyclic loading to 4 and 3 at the loading cycles up to 300 N and 400 N, respectively, because of prior failure. The number of specimens in the HSTRCI

Discussion

Hamstring and patellar tendons have become the most popular replacement grafts for ACL reconstructions. However, the ideal technique for graft fixation remains controversial, especially with hamstring tendons. This study was conducted to determine the impact of level and method of fixation on the mechanical properties of 4 hamstring reconstruction techniques and compare them with a standard patellar-tendon graft reconstruction at the time of implantation. The biomechanical properties of ACL

Acknowledgements

Acknowledgment: We thank Mrs. G. Heymann for her invaluable help with the illustrations used in this study and Dr. Maria Apreleva for her technical assistance in the software development.

References (46)

  • A Weiler et al.

    The EndoPearl device increases fixation strength and eliminates construct slippage of hamstring tendon grafts with interference screw fixation

    Arthroscopy

    (2001)
  • KC Miyasaka et al.

    The incidence of knee ligament injuries in the general population

    Am J Knee Surg

    (1991)
  • J Kartus et al.

    Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts

    Knee Surg Sports Traumatol Arthrosc

    (1997)
  • K Yasuda et al.

    Graft site morbidity with autogenous semitendinosus and gracilis tendons

    Am J Sports Med

    (1995)
  • PT Simonian et al.

    Assessment of morbidity of semitendinosus and gracilis tendon harvest for ACL reconstruction

    Am J Knee Surg

    (1997)
  • IS Corry et al.

    Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft

    Am J Sports Med

    (1999)
  • TD Rosenberg et al.

    ACL reconstruction: semitendinosus tendon is the graft of choice

    Orthopedics

    (1997)
  • DL Hamner et al.

    Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques

    J Bone Joint Surg Am

    (1999)
  • TW Wilson et al.

    A biomechanical analysis of matched bone-patellar tendon-bone and double-looped semitendinosus and gracilis tendon grafts

    Am J Sports Med

    (1999)
  • MP Wallace et al.

    In vivo tensile behavior of a four-bundle hamstring graft as a replacement for the anterior cruciate ligament

    J Orthop Res

    (1997)
  • GA Livesay et al.

    Determination of the in-situ forces and force distribution within the human anterior cruciate ligament

    Ann Biomed Eng

    (1995)
  • WA Grana et al.

    An analysis of autograft fixation after anterior cruciate ligament reconstruction in a rabbit model

    Am J Sports Med

    (1994)
  • K Blickenstaff et al.

    Analysis of a semitendinosus autograft in a rabbit model

    Am J Sports Med

    (1997)
  • Cited by (0)

    *

    Address correspondence and reprint requests to Andreas Weiler, M.D., Unfall- & Wiederherstellungschirurgie, Charité, Campus Virchow-Klinikum, Humboldt Universität zu Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany. E-mail: [email protected]

    View full text