No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft

  • Eivind InderhaugEmail author
  • Jon Olav Drogseth
  • Stein Håkon Låstad Lygre
  • Tone Gifstad



The current study investigated the distribution of hamstrings graft size and body mass index and any potential effect on the risk of revision surgery in a large prospective cohort of patients undergoing ACL reconstruction. More specifically, the aim of the study was to investigate whether larger graft size or smaller BMI would decrease the risk of revision after ACL reconstruction.


A total of 4029 patients, prospectively registered in the Norwegian Knee Ligament Registry, were included in the study. Univariate Kaplan–Meier survival analyses (with log-rank tests) and the Cox proportional hazard (PH) regression model were applied to compare risk of revision between groups of patients. Mutual adjustment for gender, age, activity at the time of injury and fixation method of the graft was performed.


Graft sizes spanned from 5.5 to 11.0 mm and the median of 8.0 mm was reported in 42% of patients in the cohort. BMI was reported from 15 to 57 with a median of 25. 46% of patients were classified as overweight (WHO standards), while 23% of patients were obese. At a median of 2.5 years after surgery, 150 patients had undergone revision surgery. Although certain effects were seen in the unadjusted analyses, neither graft size (diameter) nor patient BMI did affect the risk of undergoing revision surgery in the adjusted analyses.


Graft size and BMI was not found to be independent risk factors for undergoing ACL revision surgery. In contrast to other studies, graft size of 8 mm or larger did not have a better outcome than smaller graft sizes. A relatively large group of overweight patients undergoing ACL surgery reflects the general increase in weight seen in Western societies. Although the current study differs from previous findings, it might indicate that graft diameter is less important than previously stated.

Level of evidence

Cohort study, II.



There has been no funding for the current work.

Compliance with ethical standards

Conflict of interest

None of the authors have any conflicts of interest to declare.

Ethical approval

Ethical approval has not been sought since the NKLR has ethical approval for its enrollment of patients, and no new data has been sought for the current work.


  1. 1.
    Chalmers PN, Mall NA, Moric M, Sherman SL, Paletta GP, Bach JCB BR (2014) Does ACL reconstruction alter natural history?: A systematic literature review of long-term outcomes. J Bone Jt Surg 96:292–300CrossRefGoogle Scholar
  2. 2.
    Inderhaug E, Strand T, Fischer-Bredenbeck C, Solheim E (2013) Long-term results after reconstruction of the ACL with hamstrings autograft and transtibial femoral drilling. Knee Surg Sports Traumatol Arthrosc 21:2004–2010CrossRefGoogle Scholar
  3. 3.
    Lai C, Ardern C, Feller J, Webster K (2017) Return to sport following anterior cruciate ligament reconstruction in elite athletes: a systematic review and meta-analysis. J Sci Med Sport 20:e101CrossRefGoogle Scholar
  4. 4.
    Grassi A, Kim C, Marcheggiani Muccioli GM, Zaffagnini S, Amendola A (2017) what is the mid-term failure rate of revision ACL reconstruction? A systematic review. Clin Orthop Relat Res 475:2484–2499CrossRefGoogle Scholar
  5. 5.
    Crawford SN, Waterman BR, Lubowitz JH (2013) Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy 29:1566–1571CrossRefGoogle Scholar
  6. 6.
    Webster KE, Feller JA (2016) Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 44:2827–2832CrossRefGoogle Scholar
  7. 7.
    Steiner M (2017) Editorial commentary: size does matter—anterior cruciate ligament graft diameter affects biomechanical and clinical outcomes. Arthroscopy 33:1014–1015CrossRefGoogle Scholar
  8. 8.
    Janssen RPA, van der Velden MJF, van den Besselaar M, Reijman M (2015) Prediction of length and diameter of hamstring tendon autografts for knee ligament surgery in Caucasians. Knee Surg Sports Traumatol Arthrosc 25:1199–1204CrossRefGoogle Scholar
  9. 9.
    Magnussen RA, Lawrence JTR, West RL, Toth AP, Taylor DC, Garrett WE (2012) Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy 28:526–531CrossRefGoogle Scholar
  10. 10.
    Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT, Parker RD, Kaeding CC, Magnussen RA (2013) The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a multicenter orthopaedic outcomes network (MOON) cohort study. Arthroscopy 29:1948–1953CrossRefGoogle Scholar
  11. 11.
    Atbaşi Z, Erçin E, Erdem Y, Emre T, Atilla H, Parlak A (2017) Correlation between body mass index and quadrupled hamstring tendon autograft size in ACL reconstruction. Joints 4:198–201CrossRefGoogle Scholar
  12. 12.
    Hamner DL, Brown CH, Steiner ME, Hecker AT, Hayes WC (1999) Hamstring tendon grafts for reconstruction of the anterior cruciate ligament. JBJS 81:549–557CrossRefGoogle Scholar
  13. 13.
    Schimoler PJ, Braun DT, Miller MC, Akhavan S (2015) Quadrupled hamstring graft strength as a function of clinical sizing. Arthroscopy 31:1091–1096CrossRefGoogle Scholar
  14. 14.
    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 31:1084–1090CrossRefGoogle Scholar
  15. 15.
    Park SY, Oh H, Park S, Lee JH, Lee SH, Yoon KH (2013) Factors predicting hamstring tendon autograft diameters and resulting failure rates after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21:1111–1118CrossRefGoogle Scholar
  16. 16.
    Snaebjörnsson T, Hamrin Senorski E, Ayeni OR, Alentorn-Geli E, Krupic F, Norberg F, Karlsson J, Samuelsson K (2017) Graft diameter as a predictor for revision anterior cruciate ligament reconstruction and KOOS and EQ-5D values: a cohort study from the Swedish national knee ligament register based on 2240 patients. Am J Sports Med 45:2092–2097CrossRefGoogle Scholar
  17. 17.
    Spragg L, Chen J, Mirzayan R, Love R, Maletis G (2016) The Effect of autologous hamstring graft diameter on the likelihood for revision of anterior cruciate ligament reconstruction. Am J Sports Med 44:1475–1481CrossRefGoogle Scholar
  18. 18.
    Ranstam J, Kärrholm J, Pulkkinen P, Mäkelä K, Espehaug B, Pedersen AB, Mehnert F, Furnes O, For the NARA study group (2011) Statistical analysis of arthroplasty data. II. Guidelines. Acta Orthop 82:258–267CrossRefGoogle Scholar
  19. 19.
    Gifstad T, Foss OA, Engebretsen L, Lind M, Forssblad M, Albrektsen G, Drogset JO (2014) Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med 42:2319–2328CrossRefGoogle Scholar
  20. 20.
    Persson A, Fjeldsgaard K, Gjertsen JE, Kjellsen AB, Engebretsen L, Hole RM, Fevang JM (2014) Increased risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction: a study of 12,643 patients from the norwegian cruciate ligament registry, 2004–2012. Am J Sports Med 42:285–291CrossRefGoogle Scholar
  21. 21.
    Ranstam J, Kärrholm J, Pulkkinen P, Mäkelä K, Espehaug B, Pedersen AB, Mehnert F, Furnes O, For the NARA study group (2011) Statistical analysis of arthroplasty data. I. Introduction and background. Acta Orthop 82:253–257CrossRefGoogle Scholar
  22. 22.
    Andernord D, Björnsson H, Petzold M, Eriksson BI, Forssblad M, Karlsson J, Samuelsson K (2014) Surgical predictors of early revision surgery after anterior cruciate ligament reconstruction: results from the swedish national knee ligament register on 13,102 patients. Am J Sports Med 42:1574–1582CrossRefGoogle Scholar
  23. 23.
    Kamien PM, Hydrick JM, Replogle WH, Go LT, Barrett GR (2013) Age, graft size, and tegner activity level as predictors of failure in anterior cruciate ligament reconstruction with hamstring autograft. Am J Sports Med 41:1808–1812CrossRefGoogle Scholar
  24. 24.
    Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, McCarty EC, Spindler KP (2012) Return to play and future acl injury risk after acl reconstruction in soccer athletes from the multicenter orthopaedic outcomes network (MOON) group. Am J Sports Med 40:2517–2522CrossRefGoogle Scholar
  25. 25.
    Shelbourne KD, Benner RW, Gray T (2014) Return to sports and subsequent injury rates after revision anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 42:1395–1400CrossRefGoogle Scholar
  26. 26.
    Romero-Corral A, Somers VK, Sierra-Johnson J, Thomas RJ, Collazo-Clavell ML, Korinek J, Allison TG, Batsis JA, Sert-Kuniyoshi FH, Lopez-Jimenez F (2008) Accuracy of body mass index in diagnosing obesity in the adult general population. Int J Obes 32:959–966CrossRefGoogle Scholar
  27. 27.
    Ng M, Fleming T, Robinson M et al (2014) Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384:766–781CrossRefGoogle Scholar
  28. 28.
    Kluczynski MA, Bisson LJ, Marzo JM (2014) Does body mass index affect outcomes of ambulatory knee and shoulder surgery? Arthroscopy 30:856–865CrossRefGoogle Scholar
  29. 29.
    de Valk EJ, Moen MH, Winters M, Bakker EWP, Tamminga R, van der Hoeven H (2013) Preoperative patient and injury factors of successful rehabilitation after anterior cruciate ligament reconstruction with single-bundle techniques. Arthroscopy 29:1879–1895CrossRefGoogle Scholar
  30. 30.
    Pietrosimone B, Kuenze C, Hart JM, Thigpen C, Lepley AS, Blackburn JT, Padua DA, Grindstaff T, Davis H, Bell D (2017) Weak associations between body mass index and self-reported disability in people with unilateral anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26:1326–1334CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Surgical DepartmentHaraldsplass Deaconess HospitalBergenNorway
  2. 2.University of BergenBergenNorway
  3. 3.Trondheim University HospitalTrondheimNorway
  4. 4.Helse Bergen HFBergenNorway

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