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Biomechanical evaluation of using one hamstrings tendon for ACL reconstruction: a human cadaveric study

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Harvesting both the semitendinosus and gracilis tendons for anterior cruciate ligament (ACL) reconstruction has a negative impact on muscle strength as well as knee function and stability. With a new “All-inside” technique, using only one hamstrings tendon (semitendinosus or gracilis) is possible because of a reduction in length requirements. The research question of this in vitro study was whether the use of only one hamstrings tendon (semitendinosus or gracilis) could restore knee kinematics and in situ force in the ACL to the level of an intact knee. Ten human cadaveric knees were tested in the following conditions: (1) intact, (2) ACL-deficient, and (3) ACL reconstruction with the “All-inside” technique using the (a) single semitendinosus tendon graft, or (b) single gracilis tendon graft. Using a robotic testing system, external loads, i.e. (1) an anterior tibial load of 134-N and (2) combined rotatory loads of 10-Nm valgus and 5-Nm internal tibial torques, were applied. The multiple degrees of freedom knee kinematics and the in situ forces in the ACL and ACL grafts were determined. In response to a 134-N anterior tibial load, the use of either graft could restore anterior tibial translation to within 1.3 mm of the intact knee. The in situ forces in the two grafts were not significantly different from those of the intact ACL. Under the combined rotatory loads, both grafts could restore knee kinematics as well as the in situ force in the grafts to the level of the intact ACL. The “All-inside” technique using either the semitendinosus or gracilis tendon for ACL reconstruction could satisfactorily restore time-zero knee kinematics and the in situ forces in either graft to those for the intact ACL, supporting clinical findings.

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References

  1. Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y (2004) Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br 86:515–520

    CAS  PubMed  Google Scholar 

  2. Adachi N, Ochi M, Uchio Y, Sakai Y, Kuriwaka M, Fujihara A (2003) Harvesting hamstring tendons for ACL reconstruction influences postoperative hamstring muscle performance. Arch Orthop Trauma Surg 123:460–465

    Article  PubMed  Google Scholar 

  3. Agel J, Ransone J, Dick R, Oppliger R, Marshall SW (2007) Descriptive epidemiology of collegiate men’s wrestling injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004. J Athl Train 42:303–310

    PubMed  Google Scholar 

  4. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N (2007) Single-and double-incision double-bundle ACL reconstruction. Clin Orthop Relat Res 454:108–113

    Article  PubMed  Google Scholar 

  5. Arnason A, Andersen TE, Holme I, Engebretsen L, Bahr R (2008) Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Sports 18:40–48

    Article  CAS  PubMed  Google Scholar 

  6. Asagumo H, Kimura M, Kobayashi Y, Taki M, Takagishi K (2007) Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: surgical techniques, clinical outcomes, and complications. Arthroscopy 23:602–609

    PubMed  Google Scholar 

  7. Bonamo JJ, Krinick RM, Sporn AA (1984) Rupture of the patellar ligament after use of its central third for anterior cruciate reconstruction. A report of two cases. J Bone Joint Surg Am 66:1294–1297

    CAS  PubMed  Google Scholar 

  8. Brophy RH, Barnes R, Rodeo SA, Warren RF (2007) Prevalence of musculoskeletal disorders at the NFL Combine–trends from 1987 to 2000. Med Sci Sports Exerc 39:22–27

    Article  PubMed  Google Scholar 

  9. Cerulli G, Caraffa A, Zamarra G, Antinolfi P, Vercillo F (2006) Mid-term follow-up of ACL reconstruction with All-inside technique. Presented at 12th ESSKA Congress, Innsbruck, Austria

  10. Christen B, Jakob RP (1992) Fractures associated with patellar ligament grafts in cruciate ligament surgery. J Bone Joint Surg Br 74:617–619

    CAS  PubMed  Google Scholar 

  11. Feeley BT, Kennelly S, Barnes RP, Muller MS, Kelly BT et al (2008) Epidemiology of National Football League training camp injuries from 1998 to 2007. Am J Sports Med 36:1597–1603

    Article  PubMed  Google Scholar 

  12. Fujie H, Livesay GA, Woo SL-Y, Kashiwaguchi S, Blomstrom G (1995) The use of a universal force-moment sensor to determine in situ forces in ligaments: a new methodology. J Biomech Eng 117:1–7

    Article  CAS  PubMed  Google Scholar 

  13. Fujie H, Mabuchi K, Woo SL-Y, Livesay GA, Arai S, Tsukamoto Y (1993) The use of robotics technology to study human joint kinematics: a new methodology. J Biomech Eng 115:211–217

    Article  CAS  PubMed  Google Scholar 

  14. Handl M, Drzik M, Cerulli G, Povysil C, Chlpik J et al (2007) Reconstruction of the anterior cruciate ligament: dynamic strain evaluation of the graft. Knee Surg Sports Traumatol Arthrosc 15:233–241

    Article  PubMed  Google Scholar 

  15. Hoher J, Kanamori A, Zeminski J, Fu FH, Woo SL-Y (2001) The position of the tibia during graft fixation affects knee kinematics and graft forces for anterior cruciate ligament reconstruction. Am J Sports Med 29:771–776

    CAS  PubMed  Google Scholar 

  16. Jarvela T (2007) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc 15:500–507

    Article  PubMed  Google Scholar 

  17. Kanamori A, Woo SL-Y, Ma CB, Zeminski J, Rudy TW et al (2000) The forces in the anterior cruciate ligament and knee kinematics during a simulated pivot shift test: A human cadaveric study using robotic technology. Arthroscopy 16:633–639

    CAS  PubMed  Google Scholar 

  18. Kartus J, Stener S, Lindahl S, Engstrom B, Eriksson BI, Karlsson J (1997) Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts. Knee Surg Sports Traumatol Arthrosc 5:222–228

    Article  CAS  PubMed  Google Scholar 

  19. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T (2008) Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 36:1675–1687

    Article  PubMed  Google Scholar 

  20. Liu W, Maitland ME (2000) The effect of hamstring muscle compensation for anterior laxity in the ACL-deficient knee during gait. J Biomech 33:871–879

    Article  CAS  PubMed  Google Scholar 

  21. Livesay GA, Fujie H, Kashiwaguchi S, Morrow DA, Fu FH, Woo SL-Y (1995) Determination of the in situ forces and force distribution within the human anterior cruciate ligament. Ann Biomed Eng 23:467–474

    Article  CAS  PubMed  Google Scholar 

  22. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL-Y (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. 2002 Richard O’Connor Award paper. Arthroscopy 19:297–304

    PubMed  Google Scholar 

  23. Longo UG, King JB, Denaro V, Maffulli N (2008) Double-bundle arthroscopic reconstruction of the anterior cruciate ligament: does the evidence add up? J Bone Joint Surg Br 90:995–999

    Article  CAS  PubMed  Google Scholar 

  24. Lubowitz JH (2006) No-tunnel anterior cruciate ligament reconstruction: the transtibial all-inside technique. Arthroscopy 22: 900 e901–e911

    Google Scholar 

  25. Maletis GB, Cameron SL, Tengan JJ, Burchette RJ (2007) A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. Am J Sports Med 35:384–394

    Article  PubMed  Google Scholar 

  26. Mastrokalos DS, Springer J, Siebold R, Paessler HH (2005) Donor site morbidity and return to the preinjury activity level after anterior cruciate ligament reconstruction using ipsilateral and contralateral patellar tendon autograft: a retrospective, nonrandomized study. Am J Sports Med 33:85–93

    Article  PubMed  Google Scholar 

  27. Moon DK, Woo SL-Y, Takakura Y, Gabriel MT, Abramowitch SD (2006) The effects of refreezing on the viscoelastic and tensile properties of ligaments. J Biomech 39:1153–1157

    Article  PubMed  Google Scholar 

  28. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K et al (2007) A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23:618–628

    Article  PubMed  Google Scholar 

  29. Nakamura N, Horibe S, Sasaki S, Kitaguchi T, Tagami M et al (2002) Evaluation of active knee flexion and hamstring strength after anterior cruciate ligament reconstruction using hamstring tendons. Arthroscopy 18:598–602

    Article  PubMed  Google Scholar 

  30. Nielsen S, Helmig P (1985) Instability of knees with ligament lesions. Cadaver studies of the anterior cruciate ligament. Acta Orthop Scand 56:426–429

    Article  CAS  PubMed  Google Scholar 

  31. Ohkoshi Y, Inoue C, Yamane S, Hashimoto T, Ishida R (1998) Changes in muscle strength properties caused by harvesting of autogenous semitendinosus tendon for reconstruction of contralateral anterior cruciate ligament. Arthroscopy 14:580–584

    Article  CAS  PubMed  Google Scholar 

  32. Risberg MA, Holm I, Tjomsland O, Ljunggren E, Ekeland A (1999) Prospective study of changes in impairments and disabilities after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 29:400–412

    CAS  PubMed  Google Scholar 

  33. Rudy TW, Livesay GA, Woo SL-Y, Fu FH (1996) A combined robotic/universal force sensor approach to determine in situ forces of knee ligaments. J Biomech 29:1357–1360

    Article  CAS  PubMed  Google Scholar 

  34. Sachs RA, Daniel DM, Stone ML, Garfein RF (1989) Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 17:760–765

    Article  CAS  PubMed  Google Scholar 

  35. Sajovic M, Vengust V, Komadina R, Tavcar R, Skaza K (2006) A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up. Am J Sports Med 34:1933–1940

    Article  PubMed  Google Scholar 

  36. Sakane M, Fox RJ, Woo SL-Y, Livesay GA, Li G, Fu FH (1997) In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res 15:285–293

    Article  CAS  PubMed  Google Scholar 

  37. Shelburne KB, Torry MR, Pandy MG (2005) Effect of muscle compensation on knee instability during ACL-deficient gait. Med Sci Sports Exerc 37:642–648

    Article  PubMed  Google Scholar 

  38. Smith PA (2007) An alternative method for “all-inside” anterior cruciate ligament reconstruction. Arthroscopy 23:451

    Article  PubMed  Google Scholar 

  39. Streich NA, Friedrich K, Gotterbarm T, Schmitt H (2008) Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc 16:232–238

    Article  PubMed  Google Scholar 

  40. Sullivan D, Levy IM, Sheskier S, Torzilli PA, Warren RF (1984) Medical restraints to anterior-posterior motion of the knee. J Bone Joint Surg Am 66:930–936

    CAS  PubMed  Google Scholar 

  41. Torzilli PA, Greenberg RL, Insall J (1981) An in vivo biomechanical evaluation of anterior-posterior motion of the knee. Roentgenographic measurement technique, stress machine, and stable population. J Bone Joint Surg Am 63:960–968

    CAS  PubMed  Google Scholar 

  42. Tsuda E, Fukuda Y, Loh JC, Debski RE, Fu FH, Woo SL-Y (2002) The effect of soft-tissue graft fixation in anterior cruciate ligament reconstruction on graft-tunnel motion under anterior tibial loading. Arthroscopy 18:960–967

    Article  PubMed  Google Scholar 

  43. Woo SL-Y, Abramowitch SD, Kilger R, Liang R (2006) Biomechanics of knee ligaments: injury, healing, and repair. J Biomech 39:1–20

    Article  PubMed  Google Scholar 

  44. Woo SL-Y, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu FH (2002) The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon. A cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am 84A:907–914

    Google Scholar 

  45. Woo SL-Y, Orlando CA, Camp JF, Akeson WH (1986) Effects of postmortem storage by freezing on ligament tensile behavior. J Biomech 19:399–404

    Article  CAS  PubMed  Google Scholar 

  46. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M (2007) Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res 454:100–107

    Article  PubMed  Google Scholar 

  47. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL-Y (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30:660–666

    PubMed  Google Scholar 

  48. Yamamoto Y, Hsu WH, Woo SL-Y, Van Scyoc AH, Takakura Y, Debski RE (2004) Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med 32:1825–1832

    Article  PubMed  Google Scholar 

  49. Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy 22:240–251

    Article  PubMed  Google Scholar 

  50. Yasuda K, Tsujino J, Ohkoshi Y, Tanabe Y, Kaneda K (1995) Graft site morbidity with autogenous semitendinosus and gracilis tendons. Am J Sports Med 23:706–714

    Article  CAS  PubMed  Google Scholar 

  51. Zhang X, Curran M, Abramowitch SD, Woo SL-Y (2006) The Viscoelastic Properties of Human Hamstring Tendons. Presented at 5th World Congress on Biomaterials, Munich, Germany

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Acknowledgments

Financial support of National Institutes of Health (AR39683, T32 EB000392), Innovazione Medica, and LARS Company, which developed the equipment and instrumentation for the “All-inside” technique, are acknowledged. The support and collaboration of Prof. Giuliano Cerulli (inventor of “All-inside” technique) and Let People Move are recognized.

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Authors and Affiliations

  1. Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA, 15219, USA

    Giovanni Zamarra, Matthew B. Fisher & Savio L-Y. Woo

  2. Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy

    Giovanni Zamarra & Giuliano Cerulli

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  1. Giovanni Zamarra
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  2. Matthew B. Fisher
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  3. Savio L-Y. Woo
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  4. Giuliano Cerulli
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Correspondence to Savio L-Y. Woo.

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Zamarra, G., Fisher, M.B., Woo, S.LY. et al. Biomechanical evaluation of using one hamstrings tendon for ACL reconstruction: a human cadaveric study. Knee Surg Sports Traumatol Arthrosc 18, 11–19 (2010). https://doi.org/10.1007/s00167-009-0911-0

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  • DOI: https://doi.org/10.1007/s00167-009-0911-0

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