Hamstring Autograft With Preserved Insertions Provides Superior Outcome as Compared To Free Hamstring Autograft In ACL Surgery
Principal Author: Dr.Ravi Gupta
Presenting Author: Dr.Anubhav Malhotra
Presented at : NZIOACON 2015 at PGIMS ROHTAK
E-mail : firstname.lastname@example.org
This paper won the ” Prof. D S Grewal BEST PAPER AWARD” at NZIOACON 2015.
Authors: RAVI GUPTA, RAJ BAHADUR, ANUBHAV MALHOTRA, GLADSON DAVID MASIH, P N GUPTA
BACKGROUND: In the anterior cruciate ligament reconstruction surgery, the functional outcome may not reach the pre-injury level in all the patients. One of the reasons reported for poor post-operative patient satisfaction is lack of proprioceptive sensation provided by normal ACL. Further, the tibial side fixation of the free graft acts as another weak link in the construct. Relying on the hypothesis that preservation of the tibial insertions of the semitendinosus and gracilis tendons (STG), while using a quadrupled STG graft, may provide better function, we described a new surgical technique using quadrupled STG graft with preserved tibial insertions, with preliminary results showing better function. The present study was conducted to compare the results of the reconstructed ACL with a free graft versus a graft with preserved insertions.
MATERIALS AND METHODS: The study conducted was a prospective double blind randomized clinical trial (patients and the assessor were blinded) of 50 male sportspersons who were randomly allocated into two groups. Group I consisted of 25 patients who underwent ACL reconstruction by hamstrings tendon free autograft (technique 1) and Group II consisted of 25 patients who underwent ACL reconstruction by a technique using hamstrings tendon autograft with preserved insertions (technique 2/GMCH Technique).The patients were assessed for a minimum follow up of one year with clinical tests, Cincinnati knee score, arthrometer (KT 1000) and Tegner’s activity scale.
RESULTS: Average age of patients in group 1 was 27.21 years ( range being 18-46), whereas in group 2 patients, the average age was 27.03 years ( range being 18-46). At 12 months: the side to side difference by KT 1000 in group 1/ Group 2 was 2.44/1.36 (p value 0.02); Cincinnati knee score was 406/418.57 (p value 0.04); and difference in pre-injury and post surgery level of sports activity was 1.12/0.28 (p value 0.04). Better mechanical stability (KT 1000) correlated well with better functional outcome (Cincinnati score) in both the groups (Pearson Correlation Coefficient (r) for Group 1 -0.597; Group 2 -0.663); but the difference between the two groups was found to be statistically insignificant (two tailed p value 0.42). Better mechanical stability (KT 1000) resulted in a faster return to sports activity (Tegner’s activity scale) in group 2 patients (Spearman’s Correlation coefficient (rho) for Group 1 -0.212; Group 2 0.067), but the difference between the two groups was statistically insignificant ( two tailed p value 0.35). The average difference between cost of surgery in group 1 and group 2 was INR 10000 (USD 162), with group 2 proving to be economically favourable to the patients.
CONCLUSIONS: We conclude that arthroscopic ACL reconstruction using semitendinosus and gracilis tendons autograft with intact insertions provides better mechanical stability, better functional outcome, faster return to the same level of sports activity and a better economical outcome. However, the correlation between mechanical stability and functional outcome and correlation between mechanical stability and time of return to sports activity between the two groups was not statistically significant.