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Though five-strand hamstring autografts demonstrate greater graft diameter, postoperative outcomes are equivocal to four-strand hamstring autograft preparations: a systematic review and meta-analysis of level I and II studies

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To compare graft dimensions, functional outcomes, and failure rates following anterior cruciate ligament reconstruction (ACLR) with either five-strand or four-strand hamstring autograft options.

Methods

Three databases (MEDLINE, PubMed, and EMBASE) were searched from inception to 22 April 2023 for level I and II studies comparing five- and four-strand hamstring autografts in ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details and rehabilitation, graft diameter, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot shift test, and graft rupture were extracted. PROMs included Knee Osteoarthritis and Outcome Score (KOOS) subscales, Lysholm, and International Knee Documentation Committee (IKDC).

Results

One randomized controlled trial (RCT) and four prospective cohort studies with 572 patients were included. Graft diameters were larger in the five-strand group with a mean difference of 0.93 mm (95% CI 0.61 to 1.25, p < 0.001, I2 = 66%). The five-strand group reported statistically higher KOOS ADL subscale and Lysholm scores with a mean difference of 4.85 (95% CI 0.14 to 9.56, p = 0.04, I2 = 19%) and 3.01 (95% CI 0.48 to 5.53, p = 0.02, I2 = 0%), respectively. There were no differences in KOOS symptoms, pain, quality of life, or sports subscales, or IKDC scores. There were no differences in rates of positive Lachman test, positive pivot shift test, or graft rupture with pooled odds ratios of 0.62 (95% CI 0.13 to 2.91, n.s., I2 = 80%), 0.94 (95% CI 0.51 to 1.75, n.s., I2 = 31%), and 2.13 (95% CI 0.38 to 12.06, n.s., I2 = 0%), respectively.

Conclusions

Although five-stranded hamstring autografts had significantly larger graft diameters compared to four-stranded grafts with a mean difference of 0.93 mm, similar graft rupture rates and clinical laxity assessments were identified following ACLR. While some PROMs were statistically superior in the five-stranded hamstring groups, the threshold for the minimal clinical important difference was not reached indicating similar clinical outcomes overall.

Level of Evidence

Level II.

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Data availability

Data can be made available upon reasonable request at prushoth.vivekanantha@medportal.ca.

Abbreviations

ACL:

Anterior cruciate ligament

ACLR:

Reconstruction

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

R-AMSTAR:

Revised assessment of multiple systematic reviews

MINORS:

Methodological index for non-randomized studies

KOOS:

Knee osteoarthritis and outcome score

QoL:

Quality of life

ADL:

Activities of daily living

IKDC:

International knee documentation committee

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Authors and Affiliations

  1. Michael DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Prushoth Vivekanantha, Soroush Nedaie & Patrick Grzela

  2. Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, Hamilton, ON, 4E14L8N 3Z5, Canada

    Dan Cohen, Jeffrey Kay & Darren de SA

  3. Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan

    Yuichi Hoshino & Kanto Nagai

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  1. Prushoth Vivekanantha
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Vivekanantha, P., Nedaie, S., Grzela, P. et al. Though five-strand hamstring autografts demonstrate greater graft diameter, postoperative outcomes are equivocal to four-strand hamstring autograft preparations: a systematic review and meta-analysis of level I and II studies. Knee Surg Sports Traumatol Arthrosc 31, 4437–4447 (2023). https://doi.org/10.1007/s00167-023-07515-8

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