Clinical and functional outcomes of ACL reconstruction with tibial attachment preserving quadrupled hamstring graft

INTRODUCTION: Recent literature supports the preservation of tibial attachment of hamstring grafts to enhance ‘‘ligamentization’’ process and prevent the potential problems of free graft such as pull-out or rupture in the early post-operative period. Another factor that has gained attention in recent days is graft diameter, which can be variable and is thought to be a factor contributing to graft failure in biomechanical and clinical studies. Numerous studies have shown conflicting evidence of graft diameter directly influencing the graft failure. HYPOTHESES: The aim of this study is to present our results of ACL reconstruction with preservation of the tibial attachment of the hamstring grafts along with loop-stitched quadrupled hamstring grafts fixed with Endobutton on the femoral side and an interference screw and staple on the tibial side. METHODS: Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Paired two-tailed student t-tests were used to assess significance. RESULTS: 45 patients had associated meniscal tear with 73.3 % undergoing repair. 3 cases (4.6 %) returned to theatre including, MUA for arthrofibrosis (n=1) and meniscal repair for recurrent medial meniscus tear (n=2). Incidence of graft re-rupture was seen in 1 patient. At a mean follow-up of 2.3 years, 80% (n=51) had complete peri-operative PROMS scores. Mean peri-operative EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.001). Multiple regression analysis does not find any correlation between PROMS and graft diameter. CONCLUSION: ACL reconstruction using tibial attachment preserving hamstring graft is a simple and , reproducible, and cost-effective technique that gives consistent clinical and functional outcomes, irrespective of the graft diameter . The natural tibial side insertion provides secure fixation and adds biology to the anatomic reconstruction, possibly reducing the re-rupture and failure rate.