Article by Chadwick Prodromos, MD

“The diameter of single bundle, hamstring autograft does not significantly influence revision rate or clinical outcomes after anterior cruciate ligament reconstruction” by Wernicke et al is quite important because it correctly debunks the entire topic of evaluating Hamstring (HS) diameter for Hamstring ACLR.  After over 30 years of exclusive use of HS autograft I can conclusively state that our studies have demonstrated that the HS is ALWAYS big enough, when quadrupled, to successfully reconstruct the ACL.  I have watched with interest the many studies that have attempted to link HS size to success of the surgery.  The issue is not graft size.  The issues have always been and continue to be

1. proper graft fixation and appropriate (not overly aggressive) rehabilitation. In our published study of 150 HS ACL reconstructions we did not have a single failure using endobutton femoral and whipstitch-post tibial fixation.  Cortical suspensory fixation has the best results for HS ACLR.  Tibial fixation is trickier.  Our published clinical and biomechanical studies show the efficacy of whipstitch post fixation if performed meticulously.  Intra-tunnel fixation with the intra-fix and similar devices has proved equally reliable.  However simple interference screw fixation is probably not adequate.  The other issue of course is
2. Proper tunnel placement

Readers can take comfort in knowing that a four strand graft (whether 4 strand semitendinosus or 2 strand Semitendinosus and 2 strand Gracilis) is always strong enough for any patient IF the fixation is well carried out and the tunnels are correctly positioned. Measurements of HS graft diameters are simply not necessary and are non-contributory to graft choice decision making.

“Long-Term Outcomes in Anterior Cruciate Ligament Reconstruction: A Systematic Review of Patellar Tendon Versus Hamstring Autografts” by Poehling-Monaghan debunks the other incorrect theory sometimes used against the use of hamstring (HS) grafts: namely that, while safer, HS grafts provide inferior stability compared to BTB grafts.  In fact, our meta-analysis like the one above showed no difference.  This is also consistent with our clinical studies.  In fact, if the HS graft is meticulously fixated and well positioned tunnels are used, the stability of an HS graft is unsurpassed.  The graft is thus satisfactory for use in patients of any activity level and either gender.

Chadwick Prodromos, MD is the author of The Anterior Cruciate Ligament, 2nd Edition. Click here to download a free chapter.