SpringerLink
Log in

Single bundle hamstrings autograft preparation techniques for anterior cruciate ligament reconstruction: current concepts

  • Arthroscopy and Sports Medicine
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures, and huge variation exists in the surgical technique. Single bundle hamstrings autograft reconstruction is a common method and has good clinical outcomes. A criticism of the hamstrings autograft is a small graft diameter, often less than 8-mm, which has been associated with increased re-rupture rates. Several graft preparation techniques for single bundle hamstrings autograft exist. Perioperative decisions include the number of tendons utilized, number of graft strands, graft configuration, and femoral and tibial fixation methods. Awareness of the minimum tendon and graft length required to produce each graft variation is necessary to avoid common pitfalls. However, intraoperative graft modification is possible to maximize graft diameter, and obtain proper fixation. The objective of this current concepts review is to describe the indications, surgical anatomy, technique, intraoperative tips, clinical outcomes, and complications for single bundle hamstrings autograft preparation techniques in ACLR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Arnold MP, Calcei JG, Vogel N, Magnussen RA, Clatworthy M, Spalding T et al (2021) ACL study group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades. Knee Surg Sports Traumatol Arthrosc 29(11):3871–3876. https://doi.org/10.1007/s00167-021-06443-9

    Article  PubMed  Google Scholar 

  2. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ (2017) Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 475(10):2459–2468. https://doi.org/10.1007/s11999-017-5278-9

    Article  PubMed  PubMed Central  Google Scholar 

  3. Yaari L, Singer J, Goldberg D, Yassin M, Agar G, Lindner D et al (2024) Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-024-05317-2

    Article  PubMed  Google Scholar 

  4. Sollberger VD, Korthaus A, Barg A, Pagenstert G (2023) Long-term results after anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon autograft with a minimum follow-up of 10 years—a systematic review. Arch Orthop Trauma Surg 143(7):4277–4289. https://doi.org/10.1007/s00402-022-04687-9

    Article  CAS  PubMed  Google Scholar 

  5. Kartus J, Movin T, Karlsson J (2001) Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy 17(9):971–980. https://doi.org/10.1053/jars.2001.28979

    Article  CAS  PubMed  Google Scholar 

  6. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH (2006) Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am 88(Suppl 4):2–10. https://doi.org/10.2106/JBJS.F.00616

    Article  PubMed  Google Scholar 

  7. Chalmers PN, Mall NA, Cole BJ, Verma NN, Bush-Joseph CA, Bach BR (2013) Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: a systematic review. Arthroscopy 29(7):1235–1242. https://doi.org/10.1016/j.arthro.2013.02.015

    Article  PubMed  Google Scholar 

  8. Wen Z, Zhang H, Yan W, Mohamed SI, Zhao P, Huang X et al (2020) Oval femoral tunnel technique is superior to the conventional round femoral tunnel technique using the hamstring tendon in anatomical anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 28(7):2245–2254. https://doi.org/10.1007/s00167-019-05809-4

    Article  PubMed  Google Scholar 

  9. Krishna L, Chan CX, Lokaiah L, Chinnasamy D, Goyal S, Wang M et al (2021) Five-strand versus four-strand hamstring autografts in anterior cruciate ligament reconstruction—a prospective randomized controlled study. Arthroscopy 37(2):579–585. https://doi.org/10.1016/j.arthro.2020.08.012

    Article  PubMed  Google Scholar 

  10. Ramkumar PN, Hadley MD, Jones MH, Farrow LD (2018) Hamstring autograft in ACL reconstruction: a 13-year predictive analysis of anthropometric factors and surgeon trends relating to graft size. Orthop J Sports Med. https://doi.org/10.1177/2325967118779788

    Article  PubMed  PubMed Central  Google Scholar 

  11. Dhillon S, Pulimi R, Ayyadurai P, Venkata Sai PM, Dhillon MS, Arumugam S (2021) Knee flexion strength deficits correlate with distal extent of tendon regeneration after hamstring harvest. Preliminary data from an Ultrasound based classification. J Clin Orthop Trauma 14:156–161. https://doi.org/10.1016/j.jcot.2020.05.024

    Article  PubMed  Google Scholar 

  12. Kremen TJ, Polakof LS, Rajaee SS, Nelson TJ, Metzger MF (2018) The effect of hamstring tendon autograft harvest on the restoration of knee stability in the setting of concurrent anterior cruciate ligament and medial collateral ligament injuries. Am J Sports Med 46(1):163–170. https://doi.org/10.1177/0363546517732743

    Article  PubMed  Google Scholar 

  13. Yoo JS, Lee SJ, Jang JE, Jang Y, Kim C, In Y (2019) Biomechanical comparison of different tendon suturing techniques for three-stranded all-inside anterior cruciate ligament grafts. Orthop Traumatol-Sur 105(6):1101–1106. https://doi.org/10.1016/j.otsr.2019.06.007

    Article  Google Scholar 

  14. Pailhé R, Cavaignac E, Murgier J, Laffosse JM, Swider P (2015) Biomechanical study of ACL reconstruction grafts. J Orthop Res 33(8):1188–1196. https://doi.org/10.1002/jor.22889

    Article  PubMed  Google Scholar 

  15. Becker R, Schröder M, Röpke M, Starke C, Nebelung W (1999) Structural properties of sutures used in anchoring multistranded hamstrings in anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy 15(3):297–300. https://doi.org/10.1016/s0749-8063(99)70038-1

    Article  CAS  PubMed  Google Scholar 

  16. Palazzolo A, Rosso F, Bonasia DE, Saccia F, Rossi R (2018) Uncommon complications after anterior cruciate ligament reconstruction. Joints 6(3):188–203. https://doi.org/10.1055/s-0038-1675799

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kubota M, Ohno R, Sato T, Yamada D, Fukusato S, Kaneko K (2018) Pearls and pitfalls of the Toggleloc with Ziploop for anterior cruciate ligament reconstruction. Arthrosc Tech 7(8):e863–e867. https://doi.org/10.1016/j.eats.2018.04.007

    Article  PubMed  PubMed Central  Google Scholar 

  18. Attia AK, Nasef H, ElSweify KH, Adam MA, AbuShaaban F, Arun K (2020) 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. Orthop J Sports Med 8(8):2325967120946326. https://doi.org/10.1177/2325967120946326

    Article  PubMed  PubMed Central  Google Scholar 

  19. Krishna L, Tan XY, Thangaraja A, Wong FKL (2019) Five-strand hamstring autograft in primary anterior cruciate ligament reconstruction. J Knee Surg 32(4):366–371. https://doi.org/10.1055/s-0038-1641175

    Article  PubMed  Google Scholar 

  20. Krishna L, Panjwani T, Mok YR, Lin Wong FK, Singh A, Toh SJ (2018) Use of the 5-strand hamstring autograft technique in increasing graft size in anterior cruciate ligament reconstruction. Arthroscopy 34(9):2633–2640. https://doi.org/10.1016/j.arthro.2018.03.026

    Article  PubMed  Google Scholar 

  21. Nazari G, Barton KI, Bryant D, Getgood A, Brown CH (2021) Five- and six-strand hamstring grafts consistently produce appropriate graft diameters for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 29(9):2940–2947. https://doi.org/10.1007/s00167-020-06313-w

    Article  PubMed  Google Scholar 

  22. Orr J, Sephien A, Diaz MA, Stoops TK, Hamzavi B, Nofsinger C (2021) Viscoelastic and failure properties of two configurations of triple-folded hamstring tendons used for anterior cruciate ligament (ACL) reconstruction. Knee 29:174–182. https://doi.org/10.1016/j.knee.2021.01.029

    Article  PubMed  Google Scholar 

  23. Plaweski S, Lanternier H (2020) Is quadruple semitendinosus tendon strands autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3 years. Eur J Orthop Surg Traumatol 30(8):1473–1479. https://doi.org/10.1007/s00590-020-02729-9

    Article  PubMed  Google Scholar 

  24. Samitier G, Vinagre G (2019) Hamstring braid graft technique for anterior cruciate ligament reconstruction. Arthrosc Tech 8(8):e815–e820. https://doi.org/10.1016/j.eats.2019.03.022

    Article  PubMed  PubMed Central  Google Scholar 

  25. Walczak BE, Hetzel SJ, Akoh CC, Baer GS (2021) Intraoperative conversion to five-strand hamstring autograft configuration significantly increases anterior cruciate ligament graft diameter independent of patient characteristics. J Knee Surg 34(8):828–833. https://doi.org/10.1055/s-0039-3400955

    Article  PubMed  Google Scholar 

  26. Barros MA, Costa SC, Jaramillo DER et al (2021) A biomechanical comparison of matched four-strand and five-strand semitendinosusgracilis grafts. Rev Bras de Medicina do Esporte 27(6):578–581. https://doi.org/10.1590/1517-8692202127062021_0040

    Article  Google Scholar 

  27. Eriksson K, Cristiani R (2023) Anatomical hamstring tendons ACL reconstruction with the “linking rings” technique. J ISAKOS 8(1):57–58. https://doi.org/10.1016/j.jisako.2022.07.001

    Article  PubMed  Google Scholar 

  28. Gudas R, Rimkūnas A, Staškūnas M (2021) Large-diameter anterior cruciate ligament reconstruction technique with 8-strand semitendinosus and Gracilis graft. Arthrosc Tech 10(4):e981–e986. https://doi.org/10.1016/j.eats.2020.11.020

    Article  PubMed  PubMed Central  Google Scholar 

  29. Jagadeesh N, Dhawan T, Sheik F, Shivalingappa V (2022) Does Hamstring graft size affect functional outcome and incidence of revision surgery after primary anterior cruciate ligament (ACL) reconstruction? Cureus. https://doi.org/10.7759/cureus.21158

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kumar R, Chouhan D, Narang A, Kalra M, Choudhary R, Kumar A (2022) Comparative analysis of arthroscopic tight rope ACL reconstruction using four strand isolated semitendinosus graft and quadrupled combined hamstring graft. Arch Bone Jt Surg 10(5):426–431. https://doi.org/10.22038/ABJS.2021.49619.2463

    Article  PubMed  PubMed Central  Google Scholar 

  31. Lang E, Hardy A, Tufis O, Grimaud O, Gerometta A, Bohu Y et al (2022) Surgical technique of anterior cruciate ligament ligamentoplasty with pedicular hamstrings via an inside-out approach: BIOFAST hamstring tendons graft. Orthop Traumatol-Sur. https://doi.org/10.1016/j.otsr.2021.103192

    Article  Google Scholar 

  32. Looney AM, McCann JA, Serino J, Orman S, Rabe JL, Postma WF (2021) Anterior cruciate ligament reconstruction graft technique reliably yields grafts with 8.0-mm diameter or larger. Orthopedics 44(4):539–545. https://doi.org/10.3928/01477447-20210618-14

    Article  Google Scholar 

  33. Mahirogullari M, Kehribar L, Surucu S, Kayaalp ME, Yilmaz AK, Aydin M (2022) Comparative results of anterior cruciate ligament reconstruction with full Tibial tunnel: quadrupled semitendinosus suspensory femoral and Tibial fixation versus quadrupled semitendinosus and Gracilis suspensory femoral and Tibial screw and staple fixation. J Knee Surg. https://doi.org/10.1055/s-0042-1749396

    Article  PubMed  Google Scholar 

  34. Park HY, Gardner B, Kim JY et al (2021) Four-strand hamstring diamond braid technique for anterior cruciate ligament reconstruction. Arthrosc Tech 10(4):e1173–e1177. https://doi.org/10.1016/j.eats.2021.01.011

    Article  PubMed  PubMed Central  Google Scholar 

  35. Lowenstein NA, Haber DB, Ostergaard PJ, Collins JE, Matzkin EG (2021) All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients. Arthroscopy 37(10):3140–3148. https://doi.org/10.1016/j.arthro.2021.03.077

    Article  PubMed  Google Scholar 

  36. Weltsch D, Chan C, Dale KM et al (2021) Reduction in diameter of hamstring autograft with additional circumferential preconditioning during ACL reconstruction in a pediatric population. Orthop J Sports Med. https://doi.org/10.1177/23259671211025497

    Article  PubMed  PubMed Central  Google Scholar 

  37. Ekdahl M, Wang JHC, Ronga M, Fu FH (2008) Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16(10):935–947. https://doi.org/10.1007/s00167-008-0584-0

    Article  PubMed  Google Scholar 

  38. Greis PE, Burks RT, Bachus K, Luker MG (2001) The influence of tendon length and fit on the strength of a tendon-bone tunnel complex. A biomechanical and histologic study in the dog. Am J Sports Med 29(4):493–7. https://doi.org/10.1177/03635465010290041901

    Article  CAS  PubMed  Google Scholar 

  39. Yamazaki S, Yasuda K, Tomita F, Minami A, Tohyama H (2006) The effect of intraosseous graft length on tendon-bone healing in anterior cruciate ligament reconstruction using flexor tendon. Knee Surg Sports Traumatol Arthrosc 14(11):1086–1093. https://doi.org/10.1007/s00167-006-0110-1

    Article  PubMed  Google Scholar 

  40. Lodhia P, Nazari G, Bryant D, Getgood A, McCormack R, STABILITY Group et al (2022) Performance of 5-strand hamstring autograft anterior cruciate ligament reconstruction in the STABILITY study: a subgroup analysis. Am J Sports Med 50(13):3502–3509. https://doi.org/10.1177/03635465221128581

    Article  PubMed  PubMed Central  Google Scholar 

  41. Monaco E, Fabbri M, Redler A, Gaj E, De Carli A, Argento G et al (2019) Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation. Knee Surg Sports Traumatol Arthrosc 27(8):2577–2584. https://doi.org/10.1007/s00167-018-5275-x

    Article  PubMed  Google Scholar 

  42. Fauno P, Kaalund S (2005) Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: A prospective randomized study. Arthroscopy 21(11):1337–1341. https://doi.org/10.1016/j.arthro.2005.08.023

    Article  PubMed  Google Scholar 

  43. Eichinger M, Ploner M, Degenhart G, Rudisch A, Smekal V, Attal R et al (2023) Tunnel widening after ACL reconstruction with different fixation techniques: aperture fixation with biodegradable interference screws versus all-inside technique with suspensory cortical buttons. 5-year data from a prospective randomized trial. Arch Orthop Trauma Surg 143(11):6707–6718. https://doi.org/10.1007/s00402-023-05001-x

    Article  PubMed  PubMed Central  Google Scholar 

  44. Boniello MR, Schwingler PM, Bonner JM, Robinson SP, Cotter A, Bonner KF (2015) Impact of hamstring graft diameter on tendon strength: a biomechanical study. Arthroscopy 31(6):1084–1090. https://doi.org/10.1016/j.arthro.2014.12.023

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None applicable.

Funding

No funds, grants, or other support was received for conducting this study.

Author information

Authors and Affiliations

  1. Department of Surgery, University of Western Ontario, 1151 Richmond St, London, ON, N6A 3K7, Canada

    Alexander J. Hoffer

  2. Department of Orthopaedics, University of British Columbia, Gordon and Leslie Diamond Health Care Centre 11th floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada

    Gina K. Peck, Jordan Leith, Mark McConkey & Parth Lodhia

  3. Fraser Orthopaedic Institute, 403-233 Nelson’s Crescent, New Westminster, BC, V3L 0E4, Canada

    Parth Lodhia

Authors
  1. Alexander J. Hoffer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gina K. Peck
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jordan Leith
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mark McConkey
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Parth Lodhia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Parth Lodhia.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

The Institutional Review Board approval was not required for this review, as no protected health information was used.

Patient consent for publication

No patient consent required was required for this review.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file 1 (DOCX 20 KB)

Supplementary file 2 (MP4 92520 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hoffer, A.J., Peck, G.K., Leith, J. et al. Single bundle hamstrings autograft preparation techniques for anterior cruciate ligament reconstruction: current concepts. Arch Orthop Trauma Surg (2024). https://doi.org/10.1007/s00402-024-05412-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00402-024-05412-4

Keywords

Search

Navigation