A Comparative Study of Braided versus Standard Preparation of Autologous Hamstring Graft in Anterior Cruciate Ligament Reconstruction
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Abstract
Background: Anterior cruciate ligament (ACL) reconstruction commonly employs autologous hamstring grafts, with various techniques used for graft preparation. Standard 4-strand grafts are widely accepted; however, braided grafts have been proposed to offer improved biomechanical properties and graft fixation. This study aims to compare the clinical and functional outcomes of braided versus standard hamstring graft preparations in ACL reconstruction.
Methods: In this prospective randomized study, 171 patients undergoing primary ACL reconstruction were assigned to two groups: group A (standard graft, n = 92) and group B (braided graft, n = 79). Intraoperative data such as graft length and diameter were recorded. Clinical and functional outcomes were evaluated using International Knee Documentation Committee (IKDC) and Lysholm scores and knee range of motion (ROM) at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively.
Results: The braided graft group demonstrated a larger mean graft diameter (P = 0.492) but decreased graft length (P = 0.028). During follow-ups till 6 months, both groups showed progressive improvement but no significant difference between the two groups with respect to knee ROM, IKDC, or Lysholm scores. Difference in complications was statistically insignificant.
Conclusion: The study suggests that both standard and braided hamstring grafts are effective options for ACL reconstruction, yielding comparable short-term clinical outcomes. However, the braided technique demonstrates potential advantages in terms of increased graft thickness and uniform fixation. While these findings are promising, further in vivo studies and long-term clinical trials are necessary to validate the superiority of the braided graft technique in ACL reconstruction.
1. Gianotti SM, Marshall SW, Hume PA, Bunt L. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport. 2009;12(6):622-7. doi: 10.1016/j.jsams.2008.07.005. [PubMed: 18835221].
2. Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med. 2008;42(6):394-412. doi: 10.1136/bjsm.2008.048934. [PubMed: 18539658]. [PubMed Central: PMC3920910].
3. Conte EJ, Hyatt AE, Gatt CJ, Jr., Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014;30(7):882-90. doi: 10.1016/j.arthro.2014.03.028. [PubMed: 24951356].
4. Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev. 2017;1(11):398-408. doi: 10.1302/2058-5241.1.160032. [PubMed: 28461919]. [PubMed Central: PMC5367541].
5. Iriuchishima T, Shirakura K, Yorifuji H, Aizawa S, Fu FH. Size comparison of ACL footprint and reconstructed auto graft. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):797-803. doi: 10.1007/s00167-012-1949-y. [PubMed: 22407184].
6. Vinagre G, Kennedy NI, Chahla J, Cinque ME, Hussain ZB, Olesen ML, et al. Hamstring Graft Preparation Techniques for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2017;6(6):e2079-e84. doi: 10.1016/j.eats.2017.08.031. [PubMed: 29349000]. [PubMed Central: PMC5766355].
7. Noh JH, Yang BG, Roh YH, Kim SW, Kim W. Anterior cruciate ligament reconstruction using 4-strand hamstring autograft: conventional single-bundle technique versus oval-footprint technique. Arthroscopy. 2011;27(11):1502-10. doi: 10.1016/j.arthro.2011.06.027. [PubMed: 21924856].
8. Calvo R, Figueroa D, Figueroa F, Vaisman A, Schmidt-Hebbel A, Morales N, et al. Five-Strand Hamstring Autograft Versus Quadruple Hamstring Autograft With Graft Diameters 8.0 Millimeters or More in Anterior Cruciate Ligament Reconstruction: Clinical Outcomes With a Minimum 2-Year Follow-Up. Arthroscopy. 2017;33(5):1007-13. doi: 10.1016/j.arthro.2016.10.028. [PubMed: 28082062].
9. Fabbri M, Monaco E, Lanzetti RM, Perugia D, Guzzini M, Labianca L, et al. Single harvesting in the all-inside graft-link technique: is the graft length crucial for success? A biomechanical study. J Orthop Traumatol. 2017;18(1):17-22. doi: 10.1007/s10195-016-0420-0. [PubMed: 27435413]. [PubMed Central: PMC5310998].
10. Park K, Brusalis CM, Ganley TJ. The 8-Strand Hamstring Autograft in Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2016;5(5):e1105-e9. doi: 10.1016/j.eats.2016.06.001. [PubMed: 28224063]. [PubMed Central: PMC5310149].
11. Lubowitz JH. All-inside anterior cruciate ligament graft link: graft preparation technique. Arthrosc Tech. 2012;1(2):e165-8. doi: 10.1016/j.eats.2012.06.002. [PubMed: 23766990]. [PubMed Central: PMC3678625].
12. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. 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. 2017;475(10):2459-68. doi: 10.1007/s11999-017-5278-9. [PubMed: 28205075]. [PubMed Central: PMC5599382].
13. Duchman KR, Lynch TS, Spindler KP. Graft Selection in Anterior Cruciate Ligament Surgery: Who gets What and Why? Clin Sports Med. 2017;36(1):25-33. doi: 10.1016/j.csm.2016.08.013. [PubMed: 27871659].
14. Struewer J, Ziring E, Oberkircher L, Schüttler KF, Efe T. Isolated anterior cruciate ligament reconstruction in patients aged fifty years: comparison of hamstring graft versus bone patellar tendon-bone graft. Int Orthop. 2013;37(5):809-17. doi: 10.1007/s00264-013-1807-7. [PubMed: 23377111]. [PubMed Central: PMC3631493].
15. Samitier G, Vinagre G. Hamstring Braid Graft Technique for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2019;8(8):e815-e20. doi: 10.1016/j.eats.2019.03.022. [PubMed: 31696044]. [PubMed Central: PMC6823734].
16. Dai C, Wang F, Wang X, Wang R, Wang S, Tang S. Arthroscopic single-bundle anterior cruciate ligament reconstruction with six-strand hamstring tendon allograft versus bone patellar tendon-bone allograft. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2915-22. doi: 10.1007/s00167-015-3569-9. [PubMed: 25763849].
17. Bourke HE, Gordon DJ, Salmon LJ, Waller A, Linklater J, Pinczewski LA. The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for 'isolated' anterior cruciate ligament rupture. J Bone Joint Surg Br. 2012;94(5):630-7. doi: 10.1302/0301 620x.94b5.28675. [PubMed: 22529082].
18. Khan I, Ullah S, Khattak SK, Khan Z, Ahmad I, Khan A. Functional Outcome of Arthroscopic Anterior Cruciate
Ligament Reconstruction Using Hamstring Autograft with Fixation Using Endobutton at Femoral End and Bioabsorbable Screw at Tibial End. Mymensingh Med J. 2022;31(4):1142-7. [PubMed: 36189564].
19. Williams RJ, 3rd, Hyman J, Petrigliano F, Rozental T, Wickiewicz TL. Anterior cruciate ligament reconstruction with a four-strand hamstring tendon autograft. J Bone Joint Surg Am. 2004;86(2):225-32. doi: 10.2106/00004623-200402000 00003. [PubMed: 14960665].
20. Looney AM, Leider JD, Horn AR, Bodendorfer BM. Bioaugmentation in the surgical treatment of anterior
cruciate ligament injuries: A review of current concepts and emerging techniques. 2020;8:2050312120921057.
SAGE doi: Open Med. 10.1177/2050312120921057. [PubMed: 32435488]. [PubMed Central: PMC7222656].
21. Sliepka JM, Saper MG, Sorey W, Mand S, Battan S, Kweon CY, et al. Effect of Increased Time to Surgery on the Ability of MRI to Rule Out Medial Meniscal Tears in Young Athletes With ACL Injury. Orthop J Sports Med. 2023;11(1):23259671221141664. doi: 10.1177/23259671221141664. [PubMed: 36743735]. [PubMed Central: PMC9893379].
22. Bhardwaj A, Solanki NS, Jain H, Raichandani K, Raichandani S, Daruwalla V. Comparison of outcome after ACL reconstruction in terms of subjective assessment of symptoms and function and clinical assessment of ligament stability. J Clin Orthop Trauma. 2018;9(2):172-4. doi: 10.1016/j.jcot.2016.09.010. [PubMed: 29896023]. [PubMed Central: PMC5994999].
23. Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med. 2012;42(9):733-49. doi: 10.1007/bf03262292. [PubMed: 22784194].
24. Chappell JD, Creighton RA, Giuliani C, Yu B, Garrett WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007;35(2):235-41. doi: 10.1177/0363546506294077. [PubMed: 17092926].
25. Hagino T, Ochiai S, Senga S, Yamashita T, Wako M, Ando T, et al. Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg. 2015;135(12):1701-6. doi: 10.1007/s00402-015-2309-4. [PubMed: 26286641].
26. Spahn G, Schiltenwolf M, Hartmann B, Grifka J, Hofmann GO, Klemm HT. [The time-related risk for knee osteoarthritis after ACL injury. Results from a systematic review]. Orthopade. 2016;45(1):81-90.
doi: 10.1007/s00132-015-3170-4. [PubMed: 26450666].
27. Asif N, Ranjan R, Ahmed S, Sabir AB, Jilani LZ, Qureshi OA. Prediction of quadruple hamstring graft diameter for anterior cruciate ligament reconstruction by anthropometric measurements. Indian J Orthop. 2016;50(1):49-54. doi: 10.4103/0019-5413.173521. [PubMed: 26955176]. [PubMed Central: PMC4759874].
28. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012;28(4):526-31. doi: 10.1016/j.arthro.2011.11.024. [PubMed: 22305299].
2. Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med. 2008;42(6):394-412. doi: 10.1136/bjsm.2008.048934. [PubMed: 18539658]. [PubMed Central: PMC3920910].
3. Conte EJ, Hyatt AE, Gatt CJ, Jr., Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014;30(7):882-90. doi: 10.1016/j.arthro.2014.03.028. [PubMed: 24951356].
4. Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev. 2017;1(11):398-408. doi: 10.1302/2058-5241.1.160032. [PubMed: 28461919]. [PubMed Central: PMC5367541].
5. Iriuchishima T, Shirakura K, Yorifuji H, Aizawa S, Fu FH. Size comparison of ACL footprint and reconstructed auto graft. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):797-803. doi: 10.1007/s00167-012-1949-y. [PubMed: 22407184].
6. Vinagre G, Kennedy NI, Chahla J, Cinque ME, Hussain ZB, Olesen ML, et al. Hamstring Graft Preparation Techniques for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2017;6(6):e2079-e84. doi: 10.1016/j.eats.2017.08.031. [PubMed: 29349000]. [PubMed Central: PMC5766355].
7. Noh JH, Yang BG, Roh YH, Kim SW, Kim W. Anterior cruciate ligament reconstruction using 4-strand hamstring autograft: conventional single-bundle technique versus oval-footprint technique. Arthroscopy. 2011;27(11):1502-10. doi: 10.1016/j.arthro.2011.06.027. [PubMed: 21924856].
8. Calvo R, Figueroa D, Figueroa F, Vaisman A, Schmidt-Hebbel A, Morales N, et al. Five-Strand Hamstring Autograft Versus Quadruple Hamstring Autograft With Graft Diameters 8.0 Millimeters or More in Anterior Cruciate Ligament Reconstruction: Clinical Outcomes With a Minimum 2-Year Follow-Up. Arthroscopy. 2017;33(5):1007-13. doi: 10.1016/j.arthro.2016.10.028. [PubMed: 28082062].
9. Fabbri M, Monaco E, Lanzetti RM, Perugia D, Guzzini M, Labianca L, et al. Single harvesting in the all-inside graft-link technique: is the graft length crucial for success? A biomechanical study. J Orthop Traumatol. 2017;18(1):17-22. doi: 10.1007/s10195-016-0420-0. [PubMed: 27435413]. [PubMed Central: PMC5310998].
10. Park K, Brusalis CM, Ganley TJ. The 8-Strand Hamstring Autograft in Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2016;5(5):e1105-e9. doi: 10.1016/j.eats.2016.06.001. [PubMed: 28224063]. [PubMed Central: PMC5310149].
11. Lubowitz JH. All-inside anterior cruciate ligament graft link: graft preparation technique. Arthrosc Tech. 2012;1(2):e165-8. doi: 10.1016/j.eats.2012.06.002. [PubMed: 23766990]. [PubMed Central: PMC3678625].
12. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. 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. 2017;475(10):2459-68. doi: 10.1007/s11999-017-5278-9. [PubMed: 28205075]. [PubMed Central: PMC5599382].
13. Duchman KR, Lynch TS, Spindler KP. Graft Selection in Anterior Cruciate Ligament Surgery: Who gets What and Why? Clin Sports Med. 2017;36(1):25-33. doi: 10.1016/j.csm.2016.08.013. [PubMed: 27871659].
14. Struewer J, Ziring E, Oberkircher L, Schüttler KF, Efe T. Isolated anterior cruciate ligament reconstruction in patients aged fifty years: comparison of hamstring graft versus bone patellar tendon-bone graft. Int Orthop. 2013;37(5):809-17. doi: 10.1007/s00264-013-1807-7. [PubMed: 23377111]. [PubMed Central: PMC3631493].
15. Samitier G, Vinagre G. Hamstring Braid Graft Technique for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2019;8(8):e815-e20. doi: 10.1016/j.eats.2019.03.022. [PubMed: 31696044]. [PubMed Central: PMC6823734].
16. Dai C, Wang F, Wang X, Wang R, Wang S, Tang S. Arthroscopic single-bundle anterior cruciate ligament reconstruction with six-strand hamstring tendon allograft versus bone patellar tendon-bone allograft. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2915-22. doi: 10.1007/s00167-015-3569-9. [PubMed: 25763849].
17. Bourke HE, Gordon DJ, Salmon LJ, Waller A, Linklater J, Pinczewski LA. The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for 'isolated' anterior cruciate ligament rupture. J Bone Joint Surg Br. 2012;94(5):630-7. doi: 10.1302/0301 620x.94b5.28675. [PubMed: 22529082].
18. Khan I, Ullah S, Khattak SK, Khan Z, Ahmad I, Khan A. Functional Outcome of Arthroscopic Anterior Cruciate
Ligament Reconstruction Using Hamstring Autograft with Fixation Using Endobutton at Femoral End and Bioabsorbable Screw at Tibial End. Mymensingh Med J. 2022;31(4):1142-7. [PubMed: 36189564].
19. Williams RJ, 3rd, Hyman J, Petrigliano F, Rozental T, Wickiewicz TL. Anterior cruciate ligament reconstruction with a four-strand hamstring tendon autograft. J Bone Joint Surg Am. 2004;86(2):225-32. doi: 10.2106/00004623-200402000 00003. [PubMed: 14960665].
20. Looney AM, Leider JD, Horn AR, Bodendorfer BM. Bioaugmentation in the surgical treatment of anterior
cruciate ligament injuries: A review of current concepts and emerging techniques. 2020;8:2050312120921057.
SAGE doi: Open Med. 10.1177/2050312120921057. [PubMed: 32435488]. [PubMed Central: PMC7222656].
21. Sliepka JM, Saper MG, Sorey W, Mand S, Battan S, Kweon CY, et al. Effect of Increased Time to Surgery on the Ability of MRI to Rule Out Medial Meniscal Tears in Young Athletes With ACL Injury. Orthop J Sports Med. 2023;11(1):23259671221141664. doi: 10.1177/23259671221141664. [PubMed: 36743735]. [PubMed Central: PMC9893379].
22. Bhardwaj A, Solanki NS, Jain H, Raichandani K, Raichandani S, Daruwalla V. Comparison of outcome after ACL reconstruction in terms of subjective assessment of symptoms and function and clinical assessment of ligament stability. J Clin Orthop Trauma. 2018;9(2):172-4. doi: 10.1016/j.jcot.2016.09.010. [PubMed: 29896023]. [PubMed Central: PMC5994999].
23. Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med. 2012;42(9):733-49. doi: 10.1007/bf03262292. [PubMed: 22784194].
24. Chappell JD, Creighton RA, Giuliani C, Yu B, Garrett WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007;35(2):235-41. doi: 10.1177/0363546506294077. [PubMed: 17092926].
25. Hagino T, Ochiai S, Senga S, Yamashita T, Wako M, Ando T, et al. Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg. 2015;135(12):1701-6. doi: 10.1007/s00402-015-2309-4. [PubMed: 26286641].
26. Spahn G, Schiltenwolf M, Hartmann B, Grifka J, Hofmann GO, Klemm HT. [The time-related risk for knee osteoarthritis after ACL injury. Results from a systematic review]. Orthopade. 2016;45(1):81-90.
doi: 10.1007/s00132-015-3170-4. [PubMed: 26450666].
27. Asif N, Ranjan R, Ahmed S, Sabir AB, Jilani LZ, Qureshi OA. Prediction of quadruple hamstring graft diameter for anterior cruciate ligament reconstruction by anthropometric measurements. Indian J Orthop. 2016;50(1):49-54. doi: 10.4103/0019-5413.173521. [PubMed: 26955176]. [PubMed Central: PMC4759874].
28. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012;28(4):526-31. doi: 10.1016/j.arthro.2011.11.024. [PubMed: 22305299].
| Files | ||
| Issue | Vol 11 No 4 (2025) | |
| Section | Research Articles | |
| DOI | https://doi.org/10.18502/jost.v11i4.20287 | |
| Keywords | ||
| Anterior Cruciate Ligament Reconstruction Hamstring Tendons Graft | ||
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How to Cite
1.
Kothiyal P, Vij K, Gupta M. A Comparative Study of Braided versus Standard Preparation of Autologous Hamstring Graft in Anterior Cruciate Ligament Reconstruction. J Orthop Spine Trauma. 2025;11(4):163-9.
